HealtH and education in afgHanistan: 10 Years After – Quantity Not Quality ACBAR Policy Series | November 2011
South Western Afghanistan
& Balochistan Association for Coordination
Page 1 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality
ACBAR
Agency Coordinating Body for Afghan Relief
اﮐﺒﺮ
Kabul Nangahar Mazar Herat
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Contents
ACknoWledgementS 4
ABBreviAtionS 5
exeCutive SummAry 6
ApproACh And methodology 10
BACkground 12
SituAtion AnAlySiS 13 Awareness 13 Security 15 lack of access to health and education services 18 Lack of qualified human resources 20 poor quality of services 22 CroSS-Cutting iSSueS 28 Women and girls 28 Local decision makers 32
AreAS for further Work 33 mental health 33 persons with disabilities 33 migrants, displaced populations and returnees 35 SuStAinABility iSSueS 36
ConCluSion 37
A WAy forWArd: reCommendAtionS 38 Health –specific recommendations 38 Education – specific recommendations 38
BiBliogrAphy 40
noteS 41
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Acknowledgements AfghanAid, Afghan youth and national and Social organisation (AynSo), CAre international (CAre),
International Rescue Committee (IRC), Norwegian Refugee Council (NRC), Swedish Committee for
Afghanistan (SCA), Save the Children international, SWABAC and other organisations were essential in all
stages of this research project. Without their support and input the study would not have been possible.
ACBAr would also like to thank dr. markus michael, ms elena vuolo and dr najibullah Said for sharing their
technical expertise and insights during the research process.
Peer Review Committee
ACBAR wishes to acknowledge the significant contribution made by Dr. Ilkhom Gafurov (SCA), Ms. Anita Anastacio
(IRC) and Ms. Jamila Omar (HRRAC) who served as the Peer Review Commit ee for the report.
Written by Althea-Maria Rivas
About the Author Althea is a political and social development specialist
with twelve years of experience in Africa, Asia and the Caribbean. She has spent the last seven years living,
working or engaged with aid programming and research
in Afghanistan with various international organizations and
NGOs, in the areas of public sector reform, gender and
humanitarian assistance. Currently, Althea is a researcher
in International Development Studies at the University of
Sussex, United Kingdom. She was formerly an Adjunct
professor in the faculty of Social Science, law and
Humanities at the American University of Afghanistan.
design & layout: Miriam Hempel | www.daretoknow.co.uk
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Abbreviations
Anp Afghan national police HMIS Health Management
AnSf Afghan national Security forces Information System hp health post ACBAr Afghanistan Coordinating idp internally displaced persons Body for Afghan relief AndS Afghanistan national imf international military forces
Development Strategy imr infant mortality rate Aprp Afghanistan peace ingo international non-
and Reintegration Programme Governmental Organization AOG Armed Opposition Groups LAS Land Allocation Scheme AdB Asia Development Bank ldm local decision-maker APEP Afghanistan Primary mmr maternal mortality rate Education Programme MDG Millennium Development Goal BeSSt Building education
Support Systems for Teachers mohe ministry of higher education BhC Basic health Centres moe ministry of education BphS Basic package of health Services molSAmd ministry of labour, Social CDC Community Development Council Affairs, martyrs and disabled moph CHC Comprehensive Health Centre ministry of public health ngo CHW Community Health Worker Non-Governmental Organization
CSo Civil Society organisation NPP National Priority Programme efA education for All pACe-A partnership for Advancing Community-Based Education eQuip education Quality in Afghanistan Improvement Programme PED Provincial Education Department EMIS Education Management ttC teacher training College Information System un united nations ephS essential package of hospital Services eu european union uSAid united States Agency for International Development GoIRA Government of Islamic WB World Bank republic of Afghanistan GER Gross Enrollment Rate
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Health and Education in Afghanistan: 10 Years After – Quantity Not Quality
ACBAR Agency Coordinating Body for Afghan Relief
EXECUTIVE SUMMARY Since 2001, significant effort has been made by the the Agency Coordinating Body for Afghan relief
Government of the Islamic Republic of Afghanistan (ACBAr)4 undertook a study from July to September (GoIRA), supported by the international community, to 2011 to look at health and education from the improvehealthcareandeducation.Accesstobasichealth perspective of ordinary Afghans and non-governmental services has officially soared from approximately 9% to organisations (NGOs) working in the field. Focus group over 80%since 2001.1 Whereas, only 900,000 children discussions and workshops addressed achievements, were enrolled in school in 2001, today the ministry of shortcomings and obstacles, coping strategies and Education (MoE) puts the figure at approximately 7.3 change. According to the research findings, the main million, with 37% of them being female students.2 But all challenges in trying to provide health and education to too often, the focus has been on increasing the quantity Afghans are: a lack of awareness; insecurity; a lack of of services and their coverage, with too little attention access to facilities; a lack of human resources capacity; given to the quality of these services, the ability of the and poor quality of services. Special attention needs to population to use the services, or their sustainability. be given to the role of decision-makers and the needs A decade after the 2001 intervention and 57 billion of women and girls. Mental health, disability issues and uSd3 worth of external aid assistance later, millions of migrant communities were particularly identified as Afghans are still struggling to access basic health and areas where more work needs to be done. education services. this lack of quality in the delivery of health and education services by both government and non-governmental actors is accompanied by growing needs and expectations of local communities within an increasingly insecure environment.
Page 6 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief of educational and vocational training opportunities,
particularly in the provinces. Ultimately, poverty remains an important underlying factor in hindering access to Main Challenges healthcare and education, with a disproportionate effect on women and girls. The increased coverage claims of Awareness: the overall level of awareness within the government are not representative of the percentage communities has increased in regard to the importance of Afghans that actually have access to those services. of utilising basic healthcare services and providing Lack of Human Resources: there are not enough skilled basic education. Females have low awareness about workers in the health and education sectors. the “brain basic hygiene and health, resulting in complications drain” that has plagued Afghanistan during the last few with deliveries and lower general health levels in some decades of conflict has resulted in a chronic lack of areas. Significant gains have been made in the area of human capacity in the country today. The high levels of educational awareness, particularly on the importance of illiteracy and a lack of functional training facilities have equal education for girls and boys. further added to the problem. Security: Sustained insecurity and violence has a major impact on the ability of essential services to be delivered to the Afghan population. Attacks on facilities, educational and health personnel and intimidation of students all affect the ability of the goirA and ngos to provide services. the extent to which insecurity affects service provision varies across the country. raids and operations by the Afghan national Security forces (AnSf) and the international military forces (imf), attacks and intimidation by armed opposition groups (AOGs) and tribal conflicts all negatively impact on the ability of the population to access services and service providers to deliver services. Criminal activity, such as kidnapping and robbery, affect the willingness of people to send their children to school and of professionals to travel within areas where they feel their safety is at risk. There is a paralysing fear and anxiety among the population that is not necessarily the result of recent attacks but a consequence of living in conflict for many years. lack of Access: The number of health and education facilities has grown significantly since 2001.This increase in quantity has meant that facilities are now present in many areas of the country that previously had little or no health or education infrastructure. the recognition of this achievement was consistent among 100% of the local respondents and ngos who participated in the study.5 lack of access to and availability of health and education services, however, continues to be a major issue which has damaged the perceived legitimacy of the government. People’s access to those services is uneven and largely unmonitored. Questionable baseline data and a lack of research hinder the design of programmes to adequately address community needs. The youth population, which forms between 68
- 70% of the population,6 is concerned about the lack Women from rural and remote areas face discrimination
at health facilities, with language barriers and low levels of education in some areas compounding the problem. The availability of human resources is low and this pool Barriers to movement, isolation and low levels of becomes even smaller when the requirement is for education have had a series of negative consequences skilled workers. Many families require that only female for women and girls, from increased vulnerability to teachers and health professionals attend to the girls and disempowerment. Women and girls are particularly women in their family. Female professionals, however, vulnerable to security threats. Female professionals are are few in number. The push to roll out programmes and targeted and harassed not just by AOGs and criminal show results has meant that substantive practical human gangs but also religious leaders and local decision- resources planning has been sacrificed. makers that oppose girls’ education. Mental health Quality of Services: Significant investment has been problems, such as depression, are common among made to develop the necessary physical infrastructure women facing persistent insecurity and there are no for providing healthcare and education services and provisions or services available to help tackle this issue. training programmes that target health and education local decision-makers: religious leaders and shura7 professionals. unfortunately, projects often end there members are key players in shaping community and fail to take measures to ensure that the services attitudes about health, education and gender issues. provided in the new buildings are of good quality or They are influential actors and can play a key role in meet the needs of local communities. Professionals lack facilitating access to services by identifying teachers and adequate training, vetting is poor, service providers are healthcare staff from the community and encouraging overloaded with tasks they are not capable of carrying the community to provide security and accommodations out and remuneration is low. In addition to the lack of for service providers. however, their power can also human capacity and poor physical infrastructure, there is be used negatively when they discourage access to a lack of equipment and disrupted funding flows. Finally, healthcare and education for women and girls, misuse the limited capacity of GoIRA officials further complicates community funds or manipulate programmes for personal the ability of staff to provide quality services. benefit. The power that local decision makers hold on the Women and Girls: Cultural barriers are still present access to and quality of basic services is indicative of the throughout the country. however, awareness raising general absence of local government and the minimal efforts have produced some positive changes. The lack influence that they have, particularly in the most remote of female professionals is further exacerbated by social and insecure areas. and security-related barriers to education and movement.
Page 7 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief Land Allocation Scheme (LAS) was initiated in 2005 and
legalizes the distribution of uncultivated government land to landless returnees and idps. the lAS, however, has
proved ineffective and has not answered the needs of returnee communities.
mental health: Psycho-social problems are not being addressed adequately at health or educational facilities. There are few services provided for the large numbers of people that are psychologically traumatised by years of conflict and insecurity. Reports of mental health problems among marginalised groups such as women and youth are common. In addition, there is a close relationship between psycho-social problems and disability. persons with disabilities: one of the consequences of years of conflict in Afghanistan is the large number of persons with disabilities. there is a lack of attention being given to the unique needs of this community in both the education and health sectors. the lack of transportation assistance acts as a disincentive to accessing services. there is a lack of skilled professionals trained to deal with the special needs of the disabled community. The quality of service received is low due to a lack of appropriate medicine, equipment and low levels of knowledge. Though awareness has grown within communities about the rights of persons with disabilities, discrimination by community members is still a major obstacle. migrants, displaced populations and returnees: migratory groups, such as kuchis8, returnees and internally displaced persons (idps) are at a particular disadvantage in regard to the access and availability of services. the migration in recent years. Many refugee returnees
and IDPs have opted to simply squat on government and private land in urban centers. These informal
settlements receive few, if any, government services and are mainly assisted by NGOs. Access to services
can be hampered by local communities in the area who feel that the increased population hinders their access
to already overloaded services.
Sustainability
With transition underway and the majority of international forces expected to withdraw by 2015, doubts are growing
over the willingness of international donors to sustain their support to one of the world’s poorest countries. This
prospect leaves the positive gains of the last ten years looking increasingly fragile, undermines the impact and
sustainability of previous donor and Afghan government investments, and threatens future efforts to tackle the
lack of quality and capacity. Sustainability of services is reliant upon: sustained levels of donor funding;
increased focus on improving the quality of services and substantive human resources capacity; the development
of research programmes that shed clarity on the local reality; and the inclusion of, and better consultation with,
Afghan civil society to help ensure development projects faced with a lack of services and dwindling livelihood benefit from local knowledge. opportunities, there has been significant rural to urban
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Key Overall Recommendations that are informed and designed according to International Community assessments which evaluate the skills of workers • The international community needs to make long term and needs within the system. Follow-up evaluations funding commitments in both the health and education need to focus on the extent to which training has sectors with programming that focuses on increasing improved capacity to deliver services. the quality, not just the quantity, of services and is • A review of the monitoring and evaluation systems disbursed with the primary objective of meeting local used by the government needs to take place. people’s needs and alleviating poverty rather than Emphasis needs to be placed on the effective serving political or security goals. collection of information, the development of • Donors need to continue to prioritise female healthcare research initiatives that engage the community and and education. The training of female professionals, the increased use of outcome and performance- health awareness raising and ensuring accessible based indicators. emergency health services are key areas where • Training programmes need to target staff in rural interventions need to be focused. areas. Continuous training and professional • The international community needs to strengthen its development opportunities need to be made monitoring and disbursement mechanisms to ensure available to people working at the sub-district level quality programming is being delivered and aid as part of the incentive package. focus needs to be assistance is being properly utilised. put on overcoming key issues, such as barriers to • The international community must prioritise the movement for women in rural areas. needs of marginalised communities, such as persons • Urgent attention needs to be given to the health with disabilities, or they will continue to experience and education needs of persons with disabilities. increased vulnerability. Programmes should focus on transportation • Donors need to recognise the extent of mental health support, social protection grants for health and issues in Afghan communities and the role that it plays education and upgrading facilities to make them in hindering the ability of communities to absorb aid. accessible. increased support needs to be given for specialised • LAS administration must be strengthened and treatment within health centres. There must be better coordinated in order to ensure that settlers recognition of the impact of mental illness on the ability have access to needed services and that lAS is of students to learn within educational centres and the better supported with clinics and schools to avoid linkage between disability and mental health. returnees migrating to the closest urban centre. • InternationaldonorsandtheGovernmentofAfghanistan The NGO Community must recognise urbanisation as a reintegration • Sustainable programming needs to make use strategy for IDPs and returnees in development plans. of resources within the community. Awareness Particular efforts must be directed towards ensuring programmes need to target religious leaders and there is requisite absorption capacity in terms of local decision-makers. The Community Heath access to services and infrastructure for those residing Worker (CHW) programme has had varied results in temporary or illegal informal settlements. Government of Afghanistan • Realistic human resource planning based on the interventions that do not overinflate community expectations. actual capacity of the potential workforce needs to be • The National Priority Programmes (NPPs) should undertaken. This will inform improved overall planning focus on the development of training programmes of service delivery, give focus to training programmes and allow the government to make more targeted but the training of older persons and youth within Mechanisms need to be put in place that demand the community, particularly in peri-urban and rural higher standards from agencies implementing areas, can have a more sustainable impact and programmes in insecure areas and by remote increase the level of community ownership. management to order improve the quality of services • Insecurity cannot be allowed to be used as an delivered. excuse for poor programming and monitoring.
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APPROACH AND METHODOLOGY In June 2011, ABCAR drafted a comprehensive advocacy Participants came from Mazar, Saripul, Samangan, Takhar, strategy aimed at strengthening civil society voices Herat, Ghor, Nangahar, Kunar, Laghman, Wardak, Kabul, ahead of Parwan, Kandahar and Bamiyan. Interviewees included groups the Bonn Conference. the strategy incorporated a research of men, women, youth9, people with disabilities, local decision- component focused on health and education as these are two makers and Kuchis (nomads) between the ages of 15 and 90. of the main areas where the international community and the The focus group participants were identified through government have claimed significant achievement and that are of four great concern to the majority of local people. Cross-cut ing issues methods. Some participants were invited to participate in the of gender, local governance and security were also identified. The study by ACBAR member organisations. These were both research findings have informed this report and the advocacy beneficiaries and non-beneficiaries of the particular agency’s messages that wil be raised by the ACBAR community in the programming. Some participants were informed about the lead up to the Bonn Conference in December 2011. study through community shuras. Some heard about the study Consultations took place at the provincial level with local through other community members and asked to share their communities and individuals and at the regional level with NGOs perspectives as wel . lastly, the youth participants were al and civil society organisations (CSos). provincial focus group mobilised through AYNSO. Ef orts were made to include health discussions were held in nine provinces. in total, 430 focus workers and teachers in the focus groups where possible. group participants from 14 provinces at ended the consultations. table 1: pfg Breakdown per research group type
Female Male Youth Local Decision- Persons with Kuchis Makers Disabilities Total Number 114 127 62 57 58 12 of Participants Overal Percentage 27 30 14 13 13 3 Number of PFGs 13 13 7 7 7 1
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table2: Breakdown of provincial focus groups (pfgs)
Total Number of Overal Percentage of
Participants Participants per Province Total Number of PFGs Mazar 53 12 6 Takhar 39 9 4 Bamiyan 41 10 6 Nangahar 83 19 8 Ghor 42 10 4 Herat 64 15 7
Kandahar 55 13 7 Kabul 53 12 6 TOTAL 430 100 48
regionallevelworkshopswereheldwithngosandCSos The majority of participants were from ACBAR member in six regional centres across the country. in total, 66 organisations. in kandahar and nangahar, however, organisations participated in the five regional workshops. agencies from outside of the ACBAR membership also attended the workshops.
Table 3: Regional NGO/CSO Workshop Participation
location participants organisations mazar 16 14 Bamiyan 12 9 nangahar 16 14 herat 22 17 kandahar 15 11 totAl 81 65 women and young girls in the youth, LDM and Persons
The focus group methodology design ensured the inclusion with Disabilities focus groups; however, the majority of of marginalised groups. Ef orts were made to achieve these focus groups contained more male participants than an urban – rural balance. Participants from the outlying female.10 The Kuchis focus group consisted of only males. districts were encouraged to come to the focus groups and share their perspectives. the gender balance between male and female focus groups was approximately 50/50. Separate focus groups were held with youth, persons with disabilities and Kuchis to give the research team a deeper understanding of health and education realities from diverse perspectives. the local decision-makers (ldm) group included tribal elders, Community Development Council (CDC) members as wel as religious leaders. The study was limited, however, in its ability to access large numbers of participants from remote areas. In addition, it was difficult to achieve a 50/50 gender balance in terms of the overal number of participants. Ef orts were made to include order to give people the opportunity to express their concerns A three-pronged approach was adopted to facilitate and share their experiences ful y rather than having to rely triangulation 11 of the research findings. The insights provided on statistical analysis. As a result, a comprehensive picture during the consultations were enhanced by a desk review of of the health and education sectors and their chal enges and relevant reports and policy documents and a series of individual successes was formed. The fol owing report outlines what interviews with technical experts. this approach strengthened ACBAR sees as the main chal enges of the cur ent situation the research study by al owing the consideration of a variety of and provides suggestions for a way forward. the analysis perspectives and experiences. it also al owed the researchers and policy recommendations are drawn from the 430 local to identify gaps, common themes and disparities between voices and the input of 66 organisations that participated in the government, community and international discourses. A the research study. qualitative rather than quantitative methodology was chosen in
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BACKGROUND Developing nations have many challenges related to Already weak education and health systems that had the development and growth of their public services. had been damaged or destroyed.15 The curriculum had Afghanistan is one of the poorest countries in the world not been revised for 30 years, and virtually no modern anditisthereforenotsurprisingthatthestateofhealthand pedagogy practices had been introduced for decades. education services in the country is poor. the situation Afghanistan had one of the most unhealthy, illiterate and is further complicated by many factors that plague post- uneducated populations in the world. conflict countries, including: an unstable political system; poor economy; and ongoing violence. Consequently, the public service delivery system in Afghanistan has been severely affected. ten years after the fall of the taliban, the Afghan government still finds itself struggling to provide basic services to the population. in 2001, when the taliban fell, Afghanistan was faced with some of the lowest health and education indicators in the world. the maternal mortality rate (mmr) was
1,800 deaths per 100,000 live births.12 In some rural areas, however, the mmr was as high as 6,507 per
100,000 births.13 the infant mortality rate (imr) was 165 in every 1,000 births and life expectancy was 44.5 years.14 Official figures put the gross enrollment rate (GER) at 38% for boys’ primary education and 3% for girls’. An estimated 80% of school buildings at all levels struggled to meet the demands of the population were and had access to insecure areas where the government almost completely decimated as a consequence of years did not. In addition, since 2005 a growing number of of war. newly established national NGOs have become the Since 2002, both the health and education sectors main contractors for the BPHS. The BPHS includes a have expanded rapidly. A series of strategic plans set of high-impact interventions aimed at addressing and international compacts have guided the planning, the principal health problems of the population, with an expansion and delivery of health and education services. emphasis on the health of women and children. The the moph was able to rapidly expand the provision of EPHS identifies a standardized package of hospital primary healthcare under the Basic Package of Health services for each level of hospital. it provides guidance Services (BphS) and essential package of hospital on how the hospital sector should be staffed, equipped,
Services (ephS)16 using a flexible contracting out and provided with materials and pharmaceuticals and procedure which incorporated ngos who had already includes a referral component which tries to create been the main health services providers for decades linkages between hospitals and the BphS facilities.
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Table 4: External Assistance for Reconstruction and Development ONLY (2002-2010)17
Category Billions in uSd
Total Committed 37.6 total disbursed 28.1 Total Committed - Health 2.22 total disbursed - health 1.75 Total Committed - Education 2.41 total disbursed - education 1.72
TheimplementationofprogrammessuchastheEducation an Afghan version of the Millennium Development
Quality Improvement Programme (EQUIP), supported goals (mdgs)19 was endorsed. At the kabul by the World Bank (WB), the partnership for Advancing Conference, held in kabul in 2010, high level Afghan Community-based Education in Afghanistan (PACE-A), government officials and foreign experts endorsed and the Afghanistan Primary Education Programme an action plan to improve social and economic (APEP), the Building Education Support Systems for development, governance and security guided by the teachers (BeSSt) (funded by the united States Agency Afghanistan National Development Strategy (ANDS). for International Development (USAID) in coordination At that time, 22 National Priority Programmes (NPPs)20, with numerous school construction projects) facilitated organised into five clusters, were developed and the increase in schools buildings, students and teachers committed to by external donors. Many of the NPPs touch across the country. large scale textbook production on issues that will impact health and education. The NPP and distribution programmes have been implemented Human Resources Development Cluster contains three to support the growing student population across the programmes that deal specifically with the Health and country. in addition, overall aid for basic education has education Sectors: education for All; higher education; increased more than fivefold in Afghanistan over the past and Human Resources for Health. At the time this report five years.18 was written, the mentioned documents are waiting to The GoIRA and the international community continue be endorsed, unfortunately having undergone very little to invest in the health and education sectors. in 2004, consultation with civil society. an obstacle to the development of healthy communities. SITUATION People are often unaware of how to attend to minor health issues which, when left unattended, sometimes ANALYSIS lead to more chronic problems. Female focus group participants spoke of a lack of awareness among women Awareness in rural areas regarding basic hygiene and nutrition Health during pregnancy. Only one-third of women have at least One of the major changes over the past ten years cited one antenatal visit during pregnancy. Nearly 75% of by ngos was the increased level of knowledge within women deliver without the assistance of health personnel communities about basic healthcare. This increase was and in rural areas this number increases to 93%.21 accredited to effective community education programmes healthcare workers interviewed stated the fact that and outreach efforts. More women are using formal women often work in the fields until they are ready to healthcare services for ante and post natal care and deliver, wait too long after labour has started to seek deliveries. Awareness about the importance of having medical assistance and do not visit the doctor afterwards children vaccinated has grown. to check on their health contributed to the high maternal Even though achievements have been made in increased mortality rates. The lack of awareness among women awareness, the overall level of knowledge in communities, about basic hygiene and reproductive health remains especially in rural and remote areas, is still low and acts as a significant challenge to maintaining healthy mothers and children. This is a particular concern in emergency due to conflict, where the lack of awareness and situations, such as floods, earthquakes and displacement knowledge is compounded by the effects of shock.
Page 13 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief complicates the mat er.
“…People’s awareness about the need to send our women to be cared for during delivery has grown. Before, al the women were giving births at home. Now there are more clinics with midwives but the clinics close around 12 or 1pm each day and there are no emergency services. If a woman goes into labour in the evening she has to go to the district hospital but usual y they close by 3pm. If the district hospital is closed you have to travel to the provincial centre. Often women end up giving birth in the car or they are dying along the way. Last month our vil age lost 7 women…because of this now some people are keeping their women at home to give birth. Sometimes they wil take them to the vil age Dia or the mul ah to bless the mother. Often people are just dying.” Testimony, Ghor
Many communities stil do not understand the way the healthcare system operates under the BPHS and are unaware of what services should be provided at various facilities. the lack of knowledge about healthcare services among communities and particularly marginalised groups hampers their ability to access services and maintain a healthy lifestyle. Women are at a particular disadvantage because of isolation and cultural bar iers. people are often unaware of where to go for treatment and unable to assert their rights due to lack of knowledge about the system and where to address complaints and malpractice cases. A weak refer al system, regular turnover of NGO service providers and the diminished capacity of healthcare workers further education. evidence of this is seen in increased
enrollment rates of girls since 2001.According to the MoE,
today, 38% (or 2.7 million) of total students are girls.22
The value that is placed on education within communities has grown. this is a result of increased availability of
education facilities, outreach programmes and migration. Though the country is still embroiled in conflict, a space
has been created that allows communities, at least in more secure areas, to acknowledge the longer term
benefits of educational investment and literacy. 10 years ago we had to send our children
to Pakistan to receive education. But now we can send our children to school here.
The awareness of education has also increased: before people were blind…
Testimony, Takhar The increased presence of schools in many areas of the
country, coupled with NGO and government awareness programmes about the importance of basic education and
literacy, has encouraged communities to invest in education for their children. The experiences of returnee communities
coming back from Pakistan and Iran, where education was Education available for both boys and girls, has contributed to at itudinal Significant positive gains have been made in the area change towards education within communities. of community awareness, especially regarding women’s
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“…Before we were not interested to educate In areas struggling with insecurity, monitoring and our sons and daughters, because we did not evaluation of service delivery and of the community’s understand the importance of education, but ability to access these services may be sporadic, done when we migrated to other countries like Iran, by remote management, or neglected completely. Local Pakistan we saw the people have access to many people from the area may be able to travel to a school or facilities and we asked ourselves that why these health facilities but supervisory staff coming from outside people have such comfortable lives? As a result, the area to conduct monitoring and quality assurance we realized that this is because of education. checks may be targeted or face difficulties. In such They educated their sons and daughters; cases, even though security does not act as an obstacle therefore they are prosperous now. So we want to the population – people can access services – the to send both our sons and daughters to schools, quality of services may still be poor because of the lack but there are no schools and no teachers in our of monitoring and supervision in the area as a result of areas. When we see a person with a pen in his hand we call him teacher and we respect him …” insecurity. People’s perceptions and beliefs about the level of Testimony, Kandahar insecurity in an area, whether rooted in fact or not, may Security act as a more debilitating factor than actual incidents of violence. there is a paralysing fear within the population insecurity is a challenge to the delivery of quality health that is not necessarily the result of recent attacks or and education services in Afghanistan. It is a complex insecurity but a consequence of living in conflict for problem that affects different actors in different ways. many years. In addition, the negative psycho-social the type of insecurity in the area, the groups involved effects of the conflict are being seen more within and the associated service delivery problems and communities. Focus group participants in all 9 provinces coping strategies vary greatly from province to province spoke of increased feelings of anxiety and fear, the poor performance of students and the presence of mental health problems due to sustained exposure to trauma, violence and instability. there is a strong linkage between the psychological impact of insecurity and the ability of communities to absorb health and education aid. and sometimes from district to district. Focus group process was seen as detrimental to investment participants in regions where security was not listed in Bamiyan province; as Donors see it as as a major concern, such as Bamiyan, spoke of being a secure province. This has resulted in marginalised as aid flows were focused on insecure a feeling of neglect and isolation…” areas. Communities are facing security threats from NGO Testimony, Bamiyan a variety of sources including the imf and Aogs and more localised insecurity due to local commanders and tribal clashes. In some areas where AOGs are actively operating they are not blocking and sometimes even facilitate people’s access to public services but, because of the low quality of services, people are still unable to receive assistance. This can negatively affect people’s confidence in the legitimacy of the government, its ability to deliver services and also its ability to control levels of insecurity. Criminality is a growing issue in the urban centres, along well travelled routes and also against valuable targets such as teachers and doctors. “…Security is an issue of importance to the people of Bamiyan. The reintegration will affect their lives and are occupied with more “…Mentally people feel insecure ...even immediate localised concerns. There were differences in though there is physical security…” the levels of knowledge various groups had concerning Testimony, Samangan transition and the peace process. the youth and local
decision-makers seemed to be more informed than other there was little knowledge or understanding of the groups such as women. Focus groups in Jalalabad and transition process, the peace process and related Kandahar, where there are ongoing military operations, programmes such as the Afghanistan Peace and had a heightened awareness of the pending withdrawal ReintegrationProgramme(APRP)withinthecommunities of international troops than other areas like ghor where interviewed. NGOs were more informed and expressed security problems are more localised. These initiatives concern regarding the effect the transition of the are seen as being something that happens far away and military forces would have on security and funding for decided by political actors, interests and the international programmes. People are unsure how these processes community.
Page 15 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief because staf are often too scared to come back to work
and the communities are too scared to come to the clinic. reasons for the raids are often not provided. the raids
are inconsistent with the Additional protocols geneva
Conventions of 1949 and 1977 (Article 12)26.
in July 2011, the un Security Council adopted resolution
1998 (2011)23 which recognized at acks on schools and hospitals as a grave violation of children’s rights. The 2011 Annual Report listed a total of 197 education-related including direct at acks against schools, col ateral damage, kil ing and injury of students and teachers, threats and intimidations and forced school closures. The report also verified 47 incidents af ecting health service delivery in 2010 which included the abduction of medical staf , the looting of medical supplies, improvised explosive device at acks, col ateral damage and intimidation24. Resolution 1998 took an additional step by cal ing for perpetrators of such violence to be listed in the Secretary General’s Annual Report on Children and Armed Conflict. The 2011 report already names both the Afghan national police (Anp) and the taliban25 as parties that abuse the rights of children in situations of armed conflict. Health Raids and operations by the IMF, at acks and intimidation by AOGs and power struggles between local commanders and tribal conflicts al negatively impact on the ability of the population to access services and the ability of service providers to deliver services. people in the Southern and the eastern regions relayed incidents of being prevented from going to clinics by IMF roadblocks, sometimes even in emergency cases, for hours at a time. NGOs discussed the double negative impact of IMF raids on clinics. They said raids af ect provision and accessibility of services directly prevented by Taliban or other armed groups.
At acks and intimidation by AOGs preventing access to healthcare facilities were not frequently cited. According
to NGOs, if an at ack occurs it is more likely to be directly against a staf member or focused on acquiring medicine
and equipment or physical assets, like ambulances, than aimed at destroying the health facility itself. As a result of
these actions, healthcare facilities that should be able to provide services to the community are unable to do so
because of a lack of human, financial or physical resources. The prevalence of criminality is becoming a growing concern.
ngos in al regions included in the study referenced the increased difficulty in recruiting staf in areas plagued by
criminal activity. In such cases, some communities have mobilised to ensure the safety of health professionals
travel ing to work in the vil ages. in areas where there are several types of insecurity, however, communities said that
they were unable to guarantee the safety of professionals
coming from outside the area. This has a two pronged af ect.
It makes it harder to bring professionals from outside the
area to train others and it also makes it harder to take wil ing
individuals out of the area in order to be trained elsewhere. There is no policy or strategy framework put in place to Harassment of healthcare workers was also cited as a address the significant health service shortcomings caused reason why professionals leave their employment and take by insecurity27 throughout the country. on jobs that are sometimes outside of their field but make People commented that access to clinics is usual y not them less vulnerable.
Page 16 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief among healthcare staff. This was mainly due to the
fact that many healthcare staff receive additional salary from private sector institutions, which can substantially
increase their income and make them a prime target for criminal groups. This is rarely the case for teachers.
Education Parents expressed concern for their children’s safety because of both ongoing and regular military operations and tribal conflicts. However, raids on schools or roadblocks by IMF which hamper access to schools were described as limited. Parents were more worried that children would be injured or killed from the collateral damage of military operations or tribal conflicts. Attacks on educational facilities by Aog groups were cited as being more frequent than attacks on health facilities. NGOs commented that attacks were more common on government schools. Yet, it was also noted that people were not always clear on who was running the school and, in such areas, ngo schools were as vulnerable as government schools. This was confirmed by the insights given in the focus group discussions. Participants commented that, in areas where there are many and changing actors and areas where community members are not consulted, there can be confusion within the community as to who is doing what. One of the major issues mentioned by participants was the targeting and harassment of teachers not just by AOGs but also by criminal elements in the community. Many night letter distributions within the community were cited, particularly those targeted at female teachers or families sending their girls to school. Robbery was less of an issue with staff of education facilities than
The kidnapping and harassment of students, particularly
girls, was raised as an issue in herat, nangahar and
kandahar. respondents spoke of not sending their children to school, not only due to on-going or recent
attacks but out of a fear that had developed after previous attacks or threats and the trauma of living
through years of conflict and violence. Once an incident occurs within the community it will interrupt the education
of the students. According to people’s perceptions, this happens in two ways. parents tend to keep their
children at home, sometimes even for months, after an attack or criminal incident occurs. In addition, students
will become fearful and even depressed, affecting their ability to absorb information and learn.
The MoE has been actively working to reduce the number of attacks against schools, such as the development of
a directorate of Security and protection. in addition, an integral part of the ‘improved institutional development
goal’ of the Education forAll NPP is improved security and protection. The programme incorporates activities such
as the development of security systems for education “…One of my daughters was abducted offices and educational institutes with awareness training when she was going to school. Now I and guidelines for key staff and students on possible have stopped sending any off my girls threats. to school – it is too dangerous…” Testimony, Kandahar
Page 17 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief is a major problem for large segments of the population.
this lack of access is at ributed to a physical absence of clinics and necessary infrastructure, short hours of LACK OF ACCESS operation of health centres, lack of availability of health workers and a lack of knowledge about health services. TO HEALTH AND EDUCATION SERVICES
Health
The overal increase in the number of people that have access to healthcare has been one of the major achievements of last decade. In 2002, it was estimated that approximately only 9% of the population had access to healthcare services. Nine years later, according to official figures by the MoPH, the BPHS is available to 85% of the population.28 This is reported by the MoPH and GoIRA to have improved the quality of life for mil ions of Afghans. The MoPH access figures, however, only represent the contractual district coverage of the BphS, or rather the percentage of the population that live in districts in which primary care services are provided by NGOs under contracts with the moph or through grants to the ngos. The official figures do not represent the actual access to services of the population in rural or remote areas of those districts. This is misleading and communicates a false sense of achievement in terms of access to healthcare available to Afghans across the country. the new goal set out in the moph Strategic plan for 2011- 2015 is for 65% of the population to have access to a health facility within two hours walking distance by 2013.29 Currently, 60% of the rural population lives more than an hour’s travel time from any health facility30 and 85% live within one hour’s distance by any means of transportation, including by car31. This last statistic includes vil agers in remote areas who would have to walk 5 or 6 hours to a clinic but are only one hour away if they had access to a car. lack of transportation and physical infrastructure, such as roads, present major chal enges to healthcare access both for service providers trying to access the population and also for patients trying to receive medical assistance. This is particularly the case in rural, mountainous and remote areas. NGOs confirmed that coverage is significantly less than represented by official figures and that lack of access to health services times in an attempt to see a doctor or nurse. In some
areas, clinics are closed for several days during the week due to corruption and insecurity. people reported “…The BPHS is supposed to be covering occasions where health directors were paid to close 80% of the country, maybe in other areas it the clinic early. doctors often use the public facilities as is different but in our region coverage and a place to find patients for their private practices. They access to health services is maybe 60% or work reduced hours at the public facilities and then refer lower. Most of the rural areas still do not have and treat the majority of patients at their private practice. access to health services in their areas and patients are charged exorbitant rates for the consultation most of our people live in rural areas…” and medicine at private health facilities. This places a NGO testimony, Eastern Region financial burden upon patients who are often already
suffering from poverty. The situation becomes even Reports of non-operational clinics were common more dire when one considers the mobility and financial throughout the study. Some NGOs reported that they were obstacles that persons with disabilities or mental unable to provide the services agreed upon due to lack problems may face. If an emergency situation occurs in of funding and geographical obstacles. Clinics were either the evening, or at night, patients often have to travel to not able to be opened or had to be closed. As a result of the provincial hospital to get assistance. in the rural and these closures, in some areas the residents had to travel to remote areas this is usually impossible, especially for the district or provincial hospital for medical care. women travelling at night due to emergency situations In some places where clinics are present they are only in areas where this is culturally difficult. open and offering services to the public on a limited basis. “…the situation is better than 10 years ago... People interviewed reported that many clinics, even but we disabled still cannot access many those at the district level, have limited hours of operation public or private clinics. Our poor economic and usually close by midday. People living in rural or situation prevents us from getting medicine…” remote areas cannot afford to visit the clinic numerous Testimony, Herat
Page 18 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief
Education The number of schools in Afghanistan has risen from
3,400 in 2001 to over 13,000 in 2011.33 this increase in infrastructure has meant that, today, education is available to more Afghan children than ever before in history. The increase in students enrolled in both Islamic and secular schools has seen a similar jump going from
900,000 in 2002 to 7.3 million in 2011.34 “…There have been big changes in the last ten years…before there were no schools for boys even in our district. Now we have schools for girls…even high schools for them… Testimony, Laghman
However, lack of access to schools was one of the major frustrations that came out of the research study. 50% of the school-aged population still do not have access to
basic education due to a lack of physical infrastructure.35 In addition, of the 7.3 million students enrolled in schools approximately 15%, or nearly one million, are said to
be “permanently absent.”36 In some districts, people reported that students travel up to three hours per day in each direction to reach primary schools. In other areas, where the remoteness of the area or security issues prevents students from travel ing alone for so many hours, children go without an education. Coverage is ensured by the six types of facilities a system designed to link the different facilities together offered under the BPHS. The most basic level – is widespread among CHWs and qualified healthcare of the BphS is the health post (hp), which is staff at the other levels of the BphS. staffed by one male and one female CHW, who are voluntary non-professional staff. there are over 10,000 health posts across the country. ChWs are supposed to cover areas of 1,000 – 1,500 people32. In remote areas, where villages are far away from each other, it is difficult to maintain this coverage. CHWs tend to be poorly trained, unable to deliver all of the services they are supposed to and are unaware of how to utilise the referral system. When available, CHWs are often unable to offer proper assistance and cannot refer patients to the next appropriate level of the BphS due to lack of knowledge and/or mobility. This means that the first level of the BPHS is not operating in all of the targeted areas. in addition, the BphS is dependant on the idea that all services in the package should be available as an integrated whole as opposed to individual services. Lack of knowledge about the referral system – the discrepancies can also be found in the dif schools cannot teach the students through to Grade 9 and, when classes are of ered, the quality of teaching erent is very low. In addition, hardly any investment has been levels of schooling. grades 1 to 6 are considered made into upper secondary school teaching Grades 10 to primary schooling. Grades 7 to 9 are classified as lower 12, which is part of the reason why there is a shortage of secondary. Together, the first nine years of qualified health and education professionals. schooling There have been big improvements with comprises a complete cycle of basic education.37 education. Nevertheless, if we have a school we Lit le investment has been made into the lower secondary have no teacher. If we have a teacher we have no schools. there is a lack of teachers and an books. A big amount of money has been spent outdated and the expectations of people were higher. “… curriculum. As a result, many of the lower Testimony, Takhar secondary
Page 19 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief
Almost 45% of school buildings, however, are The MoE has created the Education Management without Information System (EMIS) which has facilitated the usable buildings, boundary wal s, safe drinking water or col ection of data in the majority of the country. Much more is known now than before about the education situation. sanitation facilities38 and the students that do at end are at risk of developing serious il nesses and health problems. However, the manner in which the data is col ected and A commonly cited reason for not sending girls to school analysed, the absence of census data, corruption within was the absence of the boundary wal . 68% of schools do the system and inability to access some areas due to not have boundary wal s and 15% require rehabilitation insecurity and remoteness result in inflated or inaccurate figures. This makes it difficult to calculate things such of their boundary wal s. Schools without boundary wal s39 leave students vulnerable to outsiders during break-times. as the number of students, the number of school-age Other impediments to access include poor planning and children and the gender parity within schools. the goirA placement of schools, unusable school buildings and high has commit ed itself to achieving six Education for Al levels of teacher absenteeism. (EFA) goals and a modified version of the global MDGs. NGOs commented that uneven distribution of schools has The Afghan MDGs have set a target of 100% participation resulted in some areas being over serviced while others in primary education by 2020. Unreliable data hinders the go without schools. moe is structured around a central possibility to accurately assess Afghanistan’s progress Ministry in Kabul and provincial and district departments towards achieving these goals. in al 34 provinces. The Provincial Education Departments LACK OF QUALIFIED (ped) are responsible for providing the moe with suggestions for the placement of schools. The mapping HUMAN RESOURCES of schools is decentralised by the moe. Both focus groups Health participants and NGOs commented that the subjectivity of The lack of skil ed workers is a major issue for NGOs this exercise paves the way for favouritism and patronage. at empting to deliver health services to the population. A lack of oversight means that rural or remote areas are local respondents spoke of the availability of only a few sometimes left out of the plan even if they do not have healthcare workers, and almost no female healthcare schools in the area. Organised community ef orts that workers, and expressed low confidence in the medical aimed to address this uneven distribution were reported to skil s of the health workers that were available. for be unsuccessful for the most part. Local-decision-makers positions that require less training or sophisticated levels commented that government officials often do not take of knowledge, such as CHWs, recruitment of staf has their requests for schools seriously. been easier for ngos, though a gap stil persists in the “…We have no school for boys or girls in recruitment of female CHWs. There are approximately our area. We have gone to the Education 18,000 CHW countrywide, with 37% being female.41 Department to discuss this many times The gap is more evident when trying to locate skil ed but they are never interested unless you doctors, nurses and medical specialists, such as pay or have relations with them… physiotherapists and gynaecologists. Some components Testimony, Nangahar of the BPHS are not implementable at al because of thie There has been a major increase in the number of lack of human resources. The mental health component Grade 12 graduates since 2001 given the significantly of the BphS requires one psychosocial counsel or to bn increased number of students attending school. present in every Comprehensive Health Centre (CHC). however, the higher education institutes are unable there are not enough people trained in psychosocial to absorb this increased number of graduates. 20% counsel ing within the entire country to fil that requirement. of students that pass the Kankor exam are unable This has a significant impact on the ability of NGOs to to secure a place within a higher education institute. provide this service. The Higher Education NPP aims to increase access by expanding facilities and raise the number of students from 62,000 (2008) to 115,000 by 2014.40 Given the gap that already exists it will be very difficult to achieve this goal and facilitate access for such a large “…There are too many people for the staff number of students. at the clinic in our area. This is particularly Oneofthemajorimpedimentstoassessingimprovements a problem for the women in the area… in the education system in Afghanistan is the difficulty of Testimony, Laghman collecting and analysing data.
Page 20 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief in schools. in addition, according to the moe, based on cur ent
demographic trends, even with drop-outs, by 2020 Afghanistan wil require an additional 99,000 teachers at the primary school
level and an additional 112,000 teachers at the secondary
school level at a cost of approximately 495 milion USD.43
Rural and remote areas are particularly af ected by the lack of skil ed workers. il iteracy tends to be higher and skil ed professionals are resistant to work in areas where they are unfamiliar. The majority of skil ed medical professionals are based in the urban areas. ngos stressed that they face difficulty recruiting staf to work in insecure and remote areas and in retaining staf due to low salaries and standards of living of ered in the outlying areas. professionals working in rural areas face a lack of services available for their families, cultural bar iers like language and limited professional growth opportunities for promotion and training. A number of healthcare staf commute from the city to the rural areas daily but this af ects their availability and increases their vulnerability to insecurity and criminality.
They are prevented from reaching communities because of distance, lack of transportation and the cost of daily travel. As a result, health facilities in the rural and remote areas are often not ful y staf ed or have to operate with staf that are not properly trained. Education There have been major eforts on the part of the MoE and the donor community to increase the number of teachers within Afghanistan to accommodate the need among students and growth in the quantity of schools. Between 2001 and 2010 there was an eight-fold increase in the number of teachers, over 170,000 of which (30%) are female.42 Whilst the number of teachers has dramaticaly increased, there are stil not enough teachers to educate the number of students enroled
every province in the country now has at least one ttC.44
there are cur ently 42 ttCs across the country but only 17 are housed in usable buildings, only 18 have dormitories
for female, and only 36 have dormitories for males.45 in provinces outside of kabul, particularly for educated
women, the TTCs are the only option for further education, training and employment. Teaching, however, is not seen
as an at ract option for those who have access to higher education. the low salary, heavy workload and poor
conditions of schools act as a deter ent. This means that the recruitment pool, even for female teachers, keeps growing,
but the retention rate is low. graduates are unlikely to remain teachers if other opportunities are made available.
Therefore, the number of students graduating from the
TTC may not be a true reflection of the number of teachers
entering the educational sector for employment. This is particularly the case with female teachers. In addition, it is
difficult to find teachers, especial y among females in the
rural areas, who meet the Grade 12 requisite for the TTC.46
As a result, the TTC model itself may not be ef ectively able to recruit the number of teachers needed for the education “…It is difficult to convince educated teachers system in Afghanistan. Whilst Significant donor funding has to work in the rural districts. The quality of life been input ed into this model not enough has been done to that they wil have there wil be lower than in the improve and accredit those who are already teaching but city. Even if they are from that area they may not want to go back to the vil age and work…” have not met the minimum education standard. NGO Testimony, Herat
Page 21 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief
POOR QUALITY OF SERVICES Health There have been many successes in the healthcare field in Afghanistan over the past ten years. The number of medical schools and training institutes has increased. There are now six medical schools in Afghanistan with approximately 8,000 students. There are nine institutes of health sciences that prepare nurses, midwives, and other health professionals with an enrllment of approximately 3,500 students.47 Vaccinations programmes targeting polio and tuberculosis have been hugely successful in both coverage and awareness rising within communities. Many health indicators have improved significantly. low quality of healthcare service provision, however, is a widespread problem. Professionals are receiving poor quality training. there is an absence of vetting processes, continuous quality improvement programmes for staff and a regularised and functioning monitoring and supervision system. The low salary fails to attract the most competent individuals, acts as a disincentive for providing quality service and is an impetus for corruption. thie lack of knowledge and capacity of staff is further compounded by regularly cited cases of inadequate resources, including a lack of equipment, medicine and ambulances. “…The main problem with the health services is the quality. The quantity is training is provided for healthcare staff but there is enough but the quality is not there…” little evidence that this has led to improvements in the Testimony, Herat from receiving qualitye healthcare. Doctors are not giving proper treatment. People are just staying sick…” The low level of knowledge among medical professionals Testimony, Saripul due to poor training and the failure to attract the most competent is a major problemgthat results in frequent misdiagnoses of illnesses, malpractice and even death. A lack of training laboratories and updated materials means that even professionals who have graduated from higher learning institutes may not be prepared to respond to the public’s needs and are sometimes unable to perform even basic procedures at the health facilities. This reaffirms an already present preference for private sectorehealthcare among theepopulation, which forces poor families into debttand excludes the poorest families provision of health services. training is not designed not car ied out in a comprehensive manner – it is these based on staff needs assessments. Instead, programmes processes that scrutinise how much knowledge is retained tend to be donor driven and focused on the quantity of from training sessions. In addition, it is difficult to provide people trained and not the quality of the training or the the level of training required by some staf recruited from skills transfer. the quality of trainers is low. they often rural communities for them to be able to deliver services do not have the capacity to train others and lack subject and understand the complexity of the BPHS system itself. knowledge. In addition, NGOs commented tha, providing The ability of health services staf to manage refer als, poor training to staff who already have limited capacity monitoring and supply systems is limited. Cultural and an, are continually overloaded greatly diminishes geographic bar iers and security concerns sometimes their ability to deliver quality servicen. Supervision prevent staf , particularly women, from at ending much and monitoring of staf and performance evaluations are needed training sessions that are of ered.
Page 22 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief
“..The government needs to prioritise women’s The lack of medicine and emergency services seems health concerns. Our women are dying on a to be a common barrier to quality health services. Due frequent basis in the rural villages and remote to an inability to effectively distribute the funds at their areas. There are no female doctors or emergency disposal, there have been unexpected funding delays services and the midwives are only working from the MoPH causing Some health centres in remote until 12pm or asking for extra money to help in areas to close for months at a time. This also resulting delivery cases. The community health workers in a lack of available drugs. ngos feel that the list of that are trained are not paid and often refuse drugs under the BPHS is unrealistic, as the medication to work. What will happen to the future of is difficult to procure and expensive. Clinics often only our country if this is not taken seriously by carry a small percentage of the drugs, sometimes less government and the international community?...” than 50%, that should be available for distribution. Testimony, Kunar There is a lack of emergency services in many areas, with no anaesthesiologists or emergency doctors able to A specific component which aims to build the stabilise critical patients. In some areas ambulances are “Capacity of health Workers” has been included in available at ChCs or even Basic health Centres (BhCs) the NPP Human Resources Development Cluster.48 but often they are only available to transport patients The component is heavily focused on increasing the from the district hospital to the provincial hospital. This number of trained workers, openins the way for similar lack of life-saving facilities was particularly problematic problems to arise. An extensive training programme that for women in need of emergency assistance due to does not speak directly to the needs, levels of education delivery complications, sick children and people trapped and capacity ofehealthcare servics providers will be in areas with ongoing military operations or tribal costly and will not result in improved quality of services conflicts. nor enhance the capacity of service providers. this is “…In some of the districts in our province one of many examples where issues could have been the clinics are closed for months at a time. We properly addressed if civil society had been adequately did an investigation and asked the clinic staff consulted during the design of the npps. why they were not open. They said they had no The low salary of healthcare workers is a major challenge medicine. They had not received money from given their increasing responsibilities. NGOs find it Kabul for two months to purchase the medicine difficult to retain qualified staff and to motivate staff to be Testimony, Ghor proactive given the low remuneration. According to the moph Strategic plan for 2011 Health workers commented that low salaries affected – 2015 there was a 91% availability of standard their ability to provide quality services to the population medicines at the national level in 2010.49 and often forced them to accept other better paid jobs. NGOs and local communities’ insights suggest a “…it is difficult to recruit and keep qualified significantly lower percentage. The MoPH’s procedures professionals because the salary is so low. regarding quality checks for pharmaceuticals exist but Even if you can recruit them they often leave are operationally quite weak. thie lack of established for jobs with a higher salary and take the training they have received with them. So rules and regulations facilitates corruption within the the capacity of the staff remains low…” system and an influx of fake drugs into the country that often end up in public health facilities. Another ngo, herat contributing factor is the diverse drug procurement procedures followed by donor agencies to the BphS. While USAID buys drugs directly and distributes them to services providers, the european union (eu) and the WB give service providers money and then the providers themselves are responsible for the procurement of the drugs. Facilities in provinces maintained by USAID tend to have better supplies of drugs and higher quality stock. The lack of capacity from the MoPH and the fragmented supply of drugs in health centres that are of varying and approach of the donor community have led to an uneven often low quality.
Page 23 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief
lowest cost bid selection processes adopted by donor People reported that they often buy their medication agencies havs severely limited the quality of services on from backroom stores in private houses. The cost of the ground. the average cost per capita of the BphS consultation and treatment varies tremendously. The low is 4 – 5 uSd.50 Competition among NGOs drives some quality of services and lack of medicine and diagnostic organizationstolowertheirfinancialbidtolessthan4USD51 capacity forces many people to seek medical treatment per capita, which has a negative effect on overall quality outside of the areas where they live. Some travel to Kabul and community satisfaction. NGOs with extremely low and others to foreign countries such as india, pakistan cost proposals are sometimes unable to practically or iran. for wealthy people the cost can be absorbed. implement services on the ground according to their Poorer people either borrow money or wait at home proposals. the technical capacity of the proposal is and sometimes even die untreated and unnecessarily. secondary to the cost, and therefore the quality of The poor quality of services not only affects people’s services suffers. those assessing the bids often do not overall level of health but also places a burden on them have the capacity and technical knowledge to determine economically, forcing people deeper into poverty. the impacts of the cost per capita on the quality of those “…Most of the people are going to the private services. doctors for their health problems. Doctors People’s preference still lies with private sector at the public clinics are unprofessional healthcare. the private sector is largely unregulated and give bad quality service…” in terms of quality of service, quality of medicine and Testimony, Mazar cost. Though people claim to receive better quality of service from private doctors the quality is still low and misdiagnose is frequent. There is no functioning quality assurance system for pharmaceuticals procured and sold at private pharmacies.
Page 24 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief Testimony, Takhar
Education in addition to and support of Afghan mdg goal 2 on targeting universal primary education by 2020, two of the NPPs focus specifically on expanding education within Afghanistan: education for All and higher Education. The NPP that focuses on primary and secondary education has made several achievements in the past few months in terms of increases in the numbes of teachers, schools and students.52 the quality of education provided, however, is poor in many areas as a result of the low quality of teaching staff in both primary and secondary schools and a lack of qualified female teachers. NGOs and community members reported that an inconsistent curriculum, no accepted evaluation standards for graduation and a lack of equipment were major additional obstacles that remain despite the increased number of schools. “…Before this ten year period, there was no attention given to female education. Now fathers agree more to send their daughters to school. It is not important if the teacher is male or female provided he/she is qualified to teach. This is what matters...” quality education in Afghanistan. the increase in
TTCs has produced more teachers. However, only 27% of existing teachers have obtained the minimum
required qualification of Grade 14 graduation. In 30 provinces less than 30% of teachers have the
minimum qualification. In Daikundi, for example,
only 1% of teachers have a Grade 14 qualification54.
Furthermore, there are regular reports of students acting as teachers or people being employed as teachers who have
had no training, or have only at ended school themselves one grade or less above their cur ent students, in order to
compensate for the lack of teachers in the area. Female
teachers are faced with bar iers to their movement that limit
their ability to receive training. in the areas where educational options are less, and the need for skil ed professionals
is greater, the quality of the teaching becomes lower.55 Therefore, the number of teachers qualified to teach at
the secondary school level wil be significantly less than
those who are able to teach at the primary level. Research
shows that it is important to have qualified teachers at the primary level in order to build a solid foundation for
a child’s education career. However, the lack of teachers
at the secondary level means that the opportunities to
continue one’s education are limited. The GoIRA aims to
significantly increase the number of teachers with a Grade
14 qualification by 2014 but, given the limits on human NGOs consistently stated that the lack of qualified resources and education opportunities in the rural areas, professional teachers is a major obstacle to providing this may be an unat ainable goal.
Page 25 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief The chronic poverty that exists in many Afghan
communities means that parents often have to make hard choices regarding their children’s education. Families A lot has changed in the past ten years but living in poverty or experiencing financial problems the focus has been too much on quantity. often rely on their children as a livelihood strategy57 to We have more schools but no professional teachers and the standards are low. My children do not even know how to read simple things and they are in high school…” Testimony, Mazar
The lack of a consistent curriculum and, accepted graduation standards contribute to uneven learning patterns across the country. Parents commented that they were disappointed with what they referred to as the absence of learning standards at schools. Across the country, students at the same level are evaluated by significantly different standards. According to MoE policy, all students from Grades 1 – 3 should automatically graduate to the next grade if they attend school regularly. Year end exams, particularly in the early Grades (1-5) are graded by individual teachers. there is an absence of a more standardized method to assess children’s foundational skills in reading and math. in grade 6 there is a national test that is supposed to determine passage to Grade 7. However, there are no accepted standards as to what skills and knowledge should be evaluated. As a result, children move through the system without being able to read to a basic standards even in 6th or 7th grades. In Mazar, parents commented that they fail to understand why their children, even at the secondary school level, cannot do simple math problems and have poor reading skills. This is a particulay problem for students from rural areas and those applying for places in higher education institutions. Furthermore, poor quality teaching furthers the lack of people who have the necessary skills to go on ano become teachers in those areas where good teaching is most needed. “…It is difficult to keep up with the changes in the curriculum. I am not sure what I should be teaching. The number of students is so many…” Testimony, Teacher, Mazar The lack of equipment, textbooks and teaching manuals in classrooms limits the ability of students to learn.According to GoIRA statistics, by 200, 15.5 million textbooks were printed and distributed for primary and secondary grades - -160056 1493andcurrently70%ofstudentsaresuppliedwithtextbo however, parent, in the focus group, consistently. oks commented,that they have to purchase textbooks from the bazaar that have been sold by the teachers. teachers. Teachers stated that they sometimes turn to
physical sanctions due to an inability to keep students engaged or to help them understand the material. This either provide additional income or in-home supports. is a poor foundation for learning.
Poorer families often cannot afford to buy textbooks or table 5: the opportunity to learn index:62 pay for transport, forcing them to make decisions about The 8 elements that need to be in place (at a which children they can afford to send to school. it is minimum) for a child to learn: often the education of the girls that is sacrificed. 1. The school year has a minimal instructional time Low time on task and insufficient hours per school of 850-1000 hours per year. year are a major impediment to the delivery of quality 2. the school is open every hour and education. Although Afghanistan has a six day school every day of the school year, and the week, between 101 and 175 days are designated school is located in the village or at least -400holiday periods, varying according to climate -50659 within 1km of the student. zone To accommodate the growing student population. 3. the teacher is present every day of the school a shift system has been adopted. According year and every hour of the school day. to the moe, over 3,000 school, have three 4. the student is present every day of the school -466shifts and some even run four shifts a day -57360 Some schoolsyear are andunable every to performhour of thethe schoolnecessary. day. number of shifts for students in the area because 5. The student-teacher ratio is within manageable teachers supplement their inadequate teacher salaries limits, assumed to be at least below 40-1. by working second jobs during the afternoon. teachers 6. Instructional materials are available for all that participated in the focus groups stated that students and used daily. sometimes only half an hour per subject is possible. 7. The school day and classroom activities are Even for Grade 6 and above contact hours may be four organized to maximize time-on-task; the effective use of time for educational purposes. hours or less61. In addition, teaching methods were a significant 8. Emphasis is placed on students developing core concern. this was expressed by both students and reading skills by the second or third grade.
Page 26 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief improved.
Thedevelopmentofeffectivepolicyanditsimplementation and oversight is dependent upon strong co-ordination among all bodies involved in delivering education services. The lack of coordination and communication between government agencies involved in education, between ministries in kabul and their related provincial departments and between the government and the NGO community is a major concern. The communication flow between the MoE, the MoHE and the MoLSAMD is fragmented and irregular. High turnover of staff at the Ministerial level means institutional knowledge is low. Changes in leadership at some Ministries has also slowed progress as each new minister tries to “reinvent the wheel”. Nevertheless, the MoE has made concerted efforts to coordinate better. The Human Resources Development Board, set up by MoE, also has participation of mohe and includes key donors, united nations (un) Agencies and ngos. Several working groups have been established under this board that are led by MoE departments. the gap between the moe in kabul and the ped in the provinces is significant. Provincial departments are scarcely staffed and the staff often lack knowledge about current educational policies and procedures. the decentralised nature of education service provision means that the MoE in Kabul is dependant on the PED for information. Communities stated that government officials at the provincial level had little knowledge about the programmes that are being implemented in their jurisdiction which contributed to the duplication of efforts. The capacity of the MoE to maintain schools after the handover by NGO partners is limited. As a result, many of the advances that are made under NGO education projects are then lost. Well trained teachers move on and retention levels fall, contributing to a drop in education standards and the amount of communication between schools and their communities. The poor salaries, gaps in communication, lack of policy knowledge, high turnover and poor oversight facilitate widespread corruption in the system by ministry staff and teachers and principals. part of the goirA plan in the next three years is to further decentralisation and train staff at the sub-national level for both administrative and financial functions. though it is important to strengthen governance functions at provincial levels, this may exacerbate already existing problems of corruption and inefficiency, especially if the monitoring capabilities of the central government are not the day because they have to help their
families financially and there are no classes in the evening for higher education…” Teaching methods and curriculum at higher education Testimony, Samangan institutes and universities are outdated. In some There are not enough qualified instructors and universities, students are asked to copy the textbook professors in higher education institutes and universities. in class as a tutorial method of learning. Laboratory Many teachers at this level are not qualified or have facilities for professional faculties, such as engineering outdated knowledge in their field. Approximately only and medicine, are ill-equipped. In universities outside the 35% of lecturers at universities have a graduate level major urban centres there may be no laboratory facilities qualification.64 this affects the quality of education that at all. Students from the youth focus groups stated that can be provided to university students. the higher it is possible to graduate from an engineering faculty education nnp proposes sending 374 current faculty without ever having built anything. libraries are poorly members abroad for Master’s and PhD training. The goal resourced and dari language translations of key texts is to have more than 50% of the faculty with Master’s and are rare. Some students opt to go to private institutions phds in three years.65 masters level training, however, which may have better facilities but not necessarily better may not be sufficient for teaching at the university level teaching standards. in addition, the cost is higher and for many subjects. In most countries a PhD can take accreditation after graduation is an issue. the quality of anywhere from 4 – 10 years to complete. The length of instruction and resources at higher education institutes time it takes to complete a PhD and questions regarding is not sufficient enough to produce a new generation of the capacity and language skills of lecturers affect the skilled professionals and academics. ability of this strategy to reap substantial impact on the “…In Samangan people are working in quality of teaching at higher education institutes in the the field. They cannot go to school during country within the next few years.
Page 27 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief South, areas thought to be traditionaly more conservative,
males expressed support for women’s education. The high maternal mortality rate has been an impetus for at itudinal
change. Acceptance of the fact that women need to be educated so they can provide healthcare services to other
women is taking hold even in more conservative regions.
CROSS-CUTTING ISSUES gender and local governance were chosen as cross- cutting issues for the research study. taking into consideration the unique position of women and girls in Afghan society and the hope that was vested in the last ten years to strengthen women’s rights, both from an international and Afghan perspective, the research study sought to examine the level of progress that had been made in this area. The study felt it was essential to recognise the important role that local governance structures – such as CdCs, local shuras and elders – have within the community in shaping attitudes towards both external actors and interventions. the role of local decision-makers was included to ascertain how they have impeded or facilitated service delivery and how NGOs could learn from positive examples. Women And Girls Awareness: Cultural and traditional bar iers are stil present throughout the country and act as major impediments to women’s education and healthcare. However, awareness raising ef orts have produced some results and these bar iers have become less of an obstacle than they were ten years ago.
Focus groups reported that they felt awareness among men about the importance of women’s healthcare and education has risen over the last ten years. even in the east and the their movement and low levels of education for women have
led to isolation, poor health and disempowerment. Awareness about the dangers of early mar iage is low
among both men and women. In some areas families use this as a coping strategy in emergency situations to generate
income. Early mar iage af ects the ability of girls to complete their education and maintain healthy lifestyles. It is rare
that girls are alowed to continue schooling after mar iage, particularly in the rural and remote areas. Mar ied girls are
often perceived as having family obligations that should
leave them with lit le spare time for education.66 this is one
of the main reasons for girls dropping out of school as they
get older.67 A further complication is the MoE policy ordering
schools to separate mar ied girls from other students and to provide separate classrooms for them. The rationale behind
the policy is that mar ied girls may discuss inappropriate topics with unmar ied girls. However, the policy applies
only to mar ied girls and not boys.68 given the shortage of
resources facing girl’s schools, the lack of female teachers
and already overcrowded classrooms, this policy pushes
mar ied girls out of the educational system. Health workers cautioned that women’s knowledge about Girls giving birth before reaching maturity are more likely basic hygiene, preventative care, ante and post-natal care to experience delivery complications. They have limited and birth spacing was very low in most areas. High levels of knowledge about how to care for themselves and basic neonatal mortality drive the level of fertility upwards and result hygiene. This contributes to the development of serious in repeated pregnancies that place women at higher levels health and nutrition concerns for women and their children, of risk from death at child birth. Al this has a serious impact yet these are preventable. on the health of women and children in the family. Bar iers to
Page 28 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief keeping them in school.
“…One of the biggest problems for girl’s education is early marriage and also that people still do not let adult girls go to school in the remote areas even if female teachers are available sometimes. In the urban areas this is not a problem…” Testimony, Nangahar
Security: Women and girls are particularly vulnerable to security threats. Following an attack, families will often send boys back to school before they allow girls to return. As a result, security incidents can have a more disruptive effect on girls’ education than boys. Female professionals are vulnerable to attacks, though this seems to be more prevalent among female teachers than female healthcare workers. Female teachers are targeted and harassed not just by AOG groups and criminal gangs but also by religious leaders and local decision-makers that oppose girls’ education. Children are also affected by the suicide attacks: they can’t concentrate to study. Women want to study too but the regular attacks are a deterrent because of the fear… Testimony, Kandahar Women are the main caretakers within families. It is rare that women themselves are actively involved in the conflict. However, they feel and must address the impact of insecurity on the men in their families who may be belligerents, anti-government or members of the army and police. Psycho-social problems, such as depression, are common among women facing persistent insecurity. “…There are too many women who have lost a brother, husband or a son. It is very painful for the women to lose so many men in one family…. Testimony, Kandahar
Access: Gaining access to school and completing their education is much more difficult for girls than it is for boys. in Afghanistan, the gender parity index (gpi) is 0.66 and
0.38 for primary and secondary school respectively.24 in addition, the MDG goal of universal primary education and the Afghanistan MDG 3 aim to promote gender equality and empower women, with the specific target of eliminating gender disparity in all levels of education no later than 2020. one of the greatest obstacles to achieving these MDG and EFA goals is the difficulty of increasing access to education for girl students and and providing better access to healthcare now and
supporting women in the community in the future. During discussions, however, both male and female Poverty is a major obstacle to women and girls’ access community members did highlight the importance of to health and education. In areas where female health prioritizing girls’ education and vocational training to professionals are only available at private institutions, create a future generation of female professionals to women from poor families that cannot afford the fees act as teachers, nurses and doctors. often have to rely on dias70 or traditional medicine “…We need to make sure girls are educated for delivery assistance and other health problems. for the future because now our women healthcare workers interviewed during the research are dying because of no medical care… study commented on some of the resultant problems Testimony, Mazar that can arise, such as infections, unintended poisoning In many areas, men have become more willing to and death during delivery. Cost of education is a send their female family members to clinics even when key deterrent to enrolment, retention and access to there are only male doctors. In 9 of the 14 provinces education services. For instance, as the government is included in the study women were allowed to go to male unable to meet the full costs of education, many families doctors. This is not the case, however, for maternity are unable to afford user fees at all, or user fees for and gynaecological issues, which are the two most all their children. Both these situations usually result in serious healthcare issues for women. The further an girls being forced to drop out of school.71 even when area is from an urban centre, the fewer female medical the desire is there on the part of families for women professionals are available and the less willing men in and girls in the family to go to school and seek proper the community are to send their women to male doctors. medical treatment, poverty is often the determining Physical/geographical constraints in access to health factor. facilities are a major challenge in most rural areas, even where basic services have been established, where donkeys are often the means of transportation women are not always able to access them. NGOs and places are sometimes completely unreachable expressed the need for communities, and particularly in winter for six months at a stretch. These issues, local decision-makers and religious leaders, to coupled with inadequate security, reduce mobility and recognise the linkage between educating women access for women.
Page 29 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief
“…In Herat women can go to male There are few female doctors, nurses, female health doctors to be examined. There are even workers and skil ed birth at endants/midwives. In some two male gynaecologists in Heart city cases they are only present at the provincial hospital level, that are assisting with births…” meaning that many women cannot access healthcare in Testimony, Herat their local areas at al unless they are al owed to see a
male doctor. In rural and remote areas, the problem is double, as facilities are less likely to have skil ed female distance and the poor quality of services were cited health workers, and local women have more difficulty as greater stumbling blocks to female education than accessing health facilities. attitudinal barriers that oppose education for girls, at Girls are often prevented from at ending school because least at the primary school level. In a recent study, 25% of the lack of female teachers. 245 out of the total 412 of participants cited distance to be a major obstacle to urban and rural districts in Afghanistan do not have a girls’ education.72 In some areas, schools located more single qualified female teacher. 200 of 412 urban and rural than three kilometres from the home were considered districts have no female students enrol ed in Grades 10 inaccessible to female students, as some respondents to12. The majority of female teachers are concentrated in considered it was not safe or not culturally appropriate urban areas: 90% of qualified female teachers are located for their daughters to walk such a distance. in the nine major urban centres (Kabul, Herat, Nangahar, Women and girls from the rural areas are fortunate if mazar, Badakhshan, takhar, Baghlan, Jawzjan and they are able to complete high school. But they have faryab).74 ngos stressed that increasing the availability even fewer opportunities to access higher education. in of female teachers is essential to ensure that education rural areas where community based informal schooling programming is in line with Islamic standards. This means is a major source of education, little effort is made to ensuring that boys and girls at end separate schools and mainstream these students into the formal education are taught by male and female teachers respectively. system. Families in rural areas are reluctant to send to address this gap, the education for All npp proposes their girls to university in kabul or the provincial capitals the use of incentives for female teachers and their if they do not have relatives living there. For women in families to go to rural districts where there is no female provinces where there is no university, the ttC is usually teacher. However, the lack of employment opportunities the only option. Currently, however, less than 50 % of for spouses and the lack of educational opportunities for TTCs have female dorms. children are strong deterrents to relocation for female “…Most of the rural areas do not have high schools for girls. If you are lucky enough teachers. It is a fact that the lack of female teachers to be able to go to a secondary school is a major obstacle to girls’ education in Afghanistan. as a girl after that the only option is the However, it should also be mentioned that, in some teachers training college. But they do not areas, NGOs have found that community acceptance of have a place to stay, so unless you have males teaching girl students is growing. In Khost and relatives you cannot go there either…” Paktika, females constitute approximately only 3% and Testimony, Ghor 5% of teachers respectively.75 ngos were able to obtain Human Resources: According to the BPHS staffing community approval for males to teach girls in Grades requirements, the cur ent demand for female doctors is 7 to 9. This is not, however, a long term sustainable more than three times the supply in the public sector. For solution to the need for more female teachers at all community midwives demand is four times the supply and teaching levels. for female nurses it is almost seven times the supply.73 in Quality of Services: Women from rural and remote areas some areas, NGOs reported that there are no midwives or face discrimination at medical facilities. Commonly cited trained female staf . by female focus groups participants from rural areas was the frustration and anxiety they feel when they have to go to health centres at the district and provincial level. they are often spoken down to, belittled and receive little attention or are sometimes completely ignored by service providers. language and education barriers in some areas exacerbate the problem.
Page 30 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief sessions that are offered to improve their skills.
“…In our area there is lots of misdiagnosis leading to death sometimes. For women it is a bigger problem because there are no female doctors and they cannot be examined properly by male doctors…” Testimony, Nangahar
It is a challenge to find qualified or educated female staff in rural areas. there is a lack of gynaecologists and obstetricians to attend to female healthcare needs throughout the country. Even when women have access to female healthcare workers the quality of care itself can be quite low resulting in complications and misdiagnosis. Women with disabilities, in both urban and rural areas, expressed frustration at the obstacles they faced in getting treatment for muscle pains related to their disability. They said it was difficult to find female physiotherapists and culturally inappropriate to go to male physiotherapists. As a result, they have to endure unnecessary pain and, depending on the type of disability they have, the problem can degenerate due to the lack of treatment. In addition, female teachers are faced with barriers to their movement that limit their ability to receive training and upgrade their capacity to teach. Cultural and geographic barriers and security concerns sometimes prevent staff, particularly women, from attending much needed training
The lack of girls’ schools, female teachers and the lower
educational qualifications of females teachers mean that the quality of education that girls have access to is low.
This is particularly the case in rural and remote areas. In addition, female students in both rural and urban areas
face both a lack of, and poor quality of, educational materials and textbooks, as well as water supply and
toilet/sanitary facilities. “…A lot of women are suffering with pain in
their bodies. We go to find a physiotherapist. The physiotherapist is male and we have to go home. We have no options. We just accept the pain…”
Testimony, Herat
In areas where formal education for girls is not permit ed
or available they can be al owed to at end classes at the
local mosque. In these situations, however, the quality of
education can be low as the instructor is not always trained
to teach or knowledgeable about the subject. Communities
interviewed in the study commented that religious leaders
sometimes disagree with girls being education and are
therefore intolerant of the girls’ presence in the mosque
so girls. in these situations, girls are only al owed to at end
classes for a short time or are sent home.
Page 31 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief community. For example, the Western region commanders
were reported as informing people about the importance of education and mobilising them to build a school and send both LOCAL DECISION their boys and girls to school. Conversely, in other districts in the region people spoke of the negative impact commanders MAKERS had on the community. Examples were given of local power brokers and commanders registering their men as teachers at
Awareness: Religious leaders and shura members are key the local schools and using the salaries provided by the moe to players in shaping communities’ at itudes on health, education support armed groups and reinforce their position and power. and gender issues. For example, mul ahs interviewed stressed the need for health and education services to always be in accordance with Islamic principles. They specifical y cal ed for more female professionals to assist with providing healthcare and education to the girls and women in their vil ages, as wel as separate schools. regarding issues such as female education and reproductive health, their active participation is key to increasing awareness within the community and encouraging behavioural change. This often means that actual awareness raising work needs to be done with the religious leaders so that they are able to assist with building awareness and knowledge. “…Our youth group had a programme to do awareness with the mullahs about girls’ education. Some progress is being made but the behaviour of the elders must be changed. They are holding back progress…” Testimony, Kunar Security: Ensuring the security of facilities and commuting professionals is one area where local decision makers can make a significant impact. They negotiate on behalf of the community with shadow governments, armed groups, AOGs and even criminal gangs.76 In several districts, agreements have been reached which facilitate service provision by alowing facilities to be open and staf and students to travel freely along the roads. These agreements, however, are vulnerable and sometimes unsustainable. Few local people spoke about ‘transition’ and the peace process as major concerns. In most cases it was only the local decision-makers who had general knowledge of these things and saw them for the most part as larger processes going on in Kabul. Information about these processes wil be handed down to the community from local decision-makers. They wil play a major part in shaping the at itudes of the community, alaying their fears and creating support or dissent. Access: Local decision-makers can play a key role in facilitating access to services. the power that they hold within the community can be used to both further and hinder the development of the community. In some areas, people reported that the local commanders had very positive influences on the hold a number of positions in the vil age or community as a
result of their position of power, though this has no relation to their expertise and the multiple responsibilities often These communities were left without any actual teachers mean that none are preformed properly. The exercise of to provide education. in such areas there is a clear inability power by local decision-makers can have both positive and on the part of the government and security forces to prevent negative impacts on the community. such behaviour. “. The local elders are very helpful in the area “…Our problem is that of local commanders. of education. They are regularly monitoring the In our district they have seriously affected community-based education classes in our area…” education. Most of the schools are closed Testimony, Parwan. because all of the teachers on the list are not Quality of Services: In some rural, remote and insecure real teachers but members of armed groups. areas, local decision makers are playing an important role Commanders take the government salary to in monitoring the quality of services provided. According support their men. We cannot stand against to the MoE, there are over 8,500 community education them and the government cannot come to shuras that work with the ministry to ensure bet er quality the area to monitor…so this continues…” education.77 Some areas also have health shuras. CHWs Testimony, Ghor are supposed to meet regularly with the community elders to discuss community needs. In areas where services are Human Resources: Local decision-makers assist with the monitored remotely, due to difficult ter ain or insecurity, recruitment of workers from the vil age or cluster level. They local decision-makers sometimes act as another checking are able to identify potential teachers for both formal and mechanism to help improve service quality. informal education and community health workers. NGOs “…In some areas the local decision-makers that do not consult with the community leadership face are always helping with health and education difficulties in implementation and jeopardise sustainability. sector. They are helping the teachers and Cor uption and patronage based appointments, however, doctors and going to the clinics…” are common. It is very common for a few individuals to Testimony, Bamiyan
Page 32 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief
AREAS FOR Donor interest in funding programmes that target persons with mental il ness is low.80 Since 2005, the BphS has included mental health services but to date these services FURTHER WORK are not provided due to insufficient donor commitment, scarce availability of adequately trained staf and training Mental Health programmes, stigma around mental il ness and poor Psycho-social problems are not being addressed fol ow-up, rehabilitation and integration into the community. adequately at health or educational facilities. there are In recognition of the extent of psycho-social problems few services provided for the large numbers of people that among youth, one of the components of the Education are psychologically traumatised. Reports of mental health for Al NPP aims to train 4,100 high school teachers as problems among marginalised groups, such as women guidance counsel ors to support students academical y and youth, are common. Both teachers and students and psycho-social y. This is an admirable goal and a involved in the study stressed the fact that the ability of service that is desperately needed in Afghan schools. the students to learn is hampered by mental health problems. lack of human resources and low educational qualifications When students are allowed to go back to school after a of teachers, however, may hinder the implementation and security incident occurs, their ability to absorb information ef ectiveness of such a programme. is limited by the fear and anxiety created by the incident. Persons With Disabilities Students that are unable to continue their education due One of the consequences of years of conflict in Afghanistan to security or lack of access to services were cited as is the large number of persons with disabilities. In addition being prone to mental health problems and vulnerable to to persons who have been disabled due to landmines or drug addiction. in addition, there is a close relationship fighting, large numbers of people have disabilities due to between psycho-social problems and disability. Persons birth defects, poor healthcare, accidents, malnutrition or with disabilities are vulnerable to the development of preventable diseases like polio. There are also many cases mental illness, such as depression. A strong stigma of learning disabilities, mental impairments (such as autism) against those with mental illness and a lack of knowledge and multiple disabilities. There have been few baseline about treatment and reintegration makes it difficult for surveys or assessments of the disabled community and those with mental illnesses to seek help. The problem is their needs in Afghanistan. The community is a diverse even more pronounced among women with disabilities one with varied and substantial needs. there is a lack of who have a higher prevalence of anxiety and depression at ention being given to the unique needs of persons with than men with disabilities.78 When unrecognised and left disabilities in both the education and health sectors. the untreated, widespread mental health problems hamper lack of transportation assistance acts as a disincentive to the development of healthy communities and the ability accessing services. there is a lack of skil ed professionals of the community to absorb assistance.79 trained to deal with the health and education needs of “…many of the students are affected by mental disabled people in Afghanistan. the quality of service health problems. They are depressed and received is low due to a lack of appropriate medicine and frustrated because their education is continually equipment and low levels of knowledge. Though awareness interrupted. They cannot learn in class, even has grown within communities about the needs and rights when the teachers are good and qualified because the students cannot absorb the information they of people with disabilities, discrimination by community are being taught because they are fearful and members is stil a major obstacle. depressed. Some are turning to drugs and some “…the disabled people may have access to have more serious mental health problems...” education, but there is an obstacle... which is poverty. We are responsible to provide life ngo, mazar necessities for our children. But the illiteracy is something inherited. Our children follow us they become illiterate. Our children are sent to do heavy work which is a breach of their human rights. If our children work to support us, they remain illiterate. Will this problem be solved? has not only affected services and education but Shall we hope that our children get educated? also the psychological situation of people…” We don’t know. Afghanistan has newly been ngo, Wardak rescued from war, education is new and security
Page 33 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief
one of the positive changes over the last ten years cited that specifically cater to disabled children. In addition, by focus group participants was the increased number of parents with disabilities who want to send their children international and national ngos working with the disabled to school are often prevented from doing so because community. However, community mobilisers stated that the of economic difficulties. Instead, children are sent to goirA had lit le idea about the scope and needs of disabled work to support the family. Some families with disabled community. Examples were provided by participants children do not send their children to school because concerning the smal support stipend given by the GoIRA. they feel that the investment in their education will be The GoIRA provides approximately 80 USD/year to wasted. disabled persons but the money is distributed monthly in “…Once I requested to study but the principal the urban centres. therefore, disabled people in rural areas of the school answered me: why do you want often cannot reach the city or do not bother because their to study, your legs are not working?.. transportation costs are greater than the stipend. Testimony, Kandahar
A specific package of services to address disabilities Awareness within the community about the needs of was included in the BphS 2005 and 2010 revisions. this persons with disabilities has grown over the past ten section of the BPHS remains underfunded and scarcely years. in spite of these additional obstacles, the ef orts implemented in most areas. Physiotherapists are supposed by persons with disabilities across the country to mobilise to be available at the district hospital level according to the themselves in the areas of health and education were BPHS staffing chart. However, they can usual y only be striking and included a variety of initiatives ranging from found in provincial hospitals. As a result, access to health family support and youth sports groups to teacher training services is severely limited for the disabled community in courses in sign language and Brail e. rural areas.81 The limited number of trained physiotherapists Disabled communities in the western region commented and other specialists, such as orthopaedists, has meant that, although the community is general y more aware of that even this minimal requirement has not been achieved. their problems, local decision-makers can be an obstacle. people with disabilities included in the study consistently They spoke of being left out of decision-making processes commented that even at the provincial hospital they were at the local level. participants said they were rarely given the unable to find qualified professionals to assist them with chance to participate and when funds are made available their health problems. District and provincial hospitals to the community, though structures like the CDCs, the often do not have any trained staf that can at end to the needs of the disabled community are not recognised. specific needs of disabled persons. Discrimination and “…There is a change from ten years ago. Now low quality services are commonplace at the hospitals. people in the community accept us more than As a result, they are forced to go to the private sector for before but we are still discriminated against healthcare. the cost of services in the private sector is high when we go for public services. We cannot even and unregulated. This places a further economic strain on gain entry to most of the clinics. It is still hard patients seeking care who are often vulnerable to poverty to find specialists who can deal with disabilities. and unemployment. There are several types of disabilities but There were severely limited education facilities for people services exist for only two types…” with learning, visual and auditory disabilities in most of the Testimony, Herat provinces. there are at least 200,000 children in Afghanistan living with a permanent disability. Approximately 65% of disabled children have access to school.37 Common reasons cited by focus group participants were lack of access to buildings, the distance of facilities and fear of harassment by students and even teachers. teachers are ill-equipped to deal with children who have disabilities. there are few facilities that train educators to work with disabled children and few schools
Page 34
Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief areas, where relevant line ministries have failed to ensure
that the necessary services are put in place when people are
building homes.83
Migrants, Displaced Popultions And Returnees A familiar backdrop to the research across Afghanistan remains the fluid migration context. This is not a new phenomenon. Migration has historicaly been a key coping mechanism for many Afghans. Refugees that returned during the last decade constitute 25% of Afghanistan’s population and a significant number have faced secondary displacement owing to the harsh realities of return, which includes landlessness, lack of employment opportunities, insecurity and weak access to basic service provision. in al areas of the country, internal displacement is a growing phenomenon with exponential rises in new idp caseloads recorded. the total IDP population in the country is estimated at 485,539 persons as of 31st September 2011 and this data does not included IDPs scat ered in urban and semi-urban areas. The LAS strategy has not met expectations. The rate of departure of residents has been as high as 80% in a few lASs, due to the lack of livelihoods and inadequate provision of basic services, particularly health and education in some
“…We have no services in the township. There was a mobile clinic but they do not
come any more. Now we have to travel to the provincial capital for medical care but people in the township are poor. We have no money
for transportation. So people just stay home when they are sick …and sometimes they
just stay sick and sometimes they die…” Testimony, Nangahar
faced with a lack of services and dwindling livelihood
opportunities, there has been significant rural to urban migration in recent years. Many refugee returnees
and IDPs have opted to simply squat on government and private land in urban centers and these informal
settlements now shelter about 80% of Kabul’s population and cover 69% of the city’s residential land. These
settlements receive few, if any, government services and are mainly assisted by NGOs. Yet, while the majority of
returnees and IDPs living in informal settlements remain particularly vulnerable and live in situations of chronic
poverty, their integration into urban areas has generally been more successful than in rural areas.
Page 35 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief
They have accessed local schools and labour markets and, despite extreme hardships, have achieved a SUSTAINABILITY degree of sustainability in their lives allowing them to make some progress towards recovery84. yet, at the ISSUES current rate of urbanization, and as the steady influx of As the transition process begins, concerns are rising as returnees and idps continues, overcrowding and severe to what the fate of Afghanistan will be, with 2014 just pressure on service provision will grow to untenable around the corner. it is doubtful that the Afghan state rates, particularly around kabul, herat and Jalalabad. will be in a position by 2015 to provide basic services
By 2015, the number of urban residents in Afghanistan to all of its citizens.85 in addition, a significant amount is expected to double. Yet municipal planning and of the external assistance that comes to Afghanistan coordination between line ministries remains extremely goes towards security. 51% of external assistance slow to respond to the service provision needs of these disbursed to date has been invested in security, whilst populations. Planning for and mitigating against the the remaining 49% has supported reconstruction and negative impact of increased migration needs to be a development activities across all different sectors.86 priority for the Government of Afghanistan. Both the health and education sectors are heavily migratory groups are at a particular disadvantage in reliant on external funding. regard to the access and availability of services. lack rapid and substantial drops in funding could cripple of physical infrastructure, discrimination and poverty all the health and education services across the country. present problems to migratory communities. They have Serious consequences could come about as a result. specialhealthneedsandaremoresusceptibletodiseases Such actions could have devastating ef ects on the caused by natural disasters and other emergencies overal development of the Afghan population, fuel created by insecurity. There is a lack of mobile clinics to uneven development across the country, increase the service Kuchi communities and those living in LASs tend negative perceptions of the local population regarding the to suffer from inconsistent access to basic education and legitimacy of the government and their wil ingness to rely health services depending on the site location. idps and on and trust local government and increase frustration returnees are sometimes unaware of which healthcare towards the international community. Sustainability of services are available in the area. services is reliant upon sustained levels of donor funding Their access to services can be hampered by individuals that is delivered absent of political agendas and that from the local communities in the area where they are directly targets the needs of the people. donors need residing who feel that the increased population hinders to increase their focus on improving the quality of and their access to already overloaded services. Girls moving access to services, make substantive developments back to conservative areas face difficulty in accessing to the human resources capacity of Afghans, support education due to cultural barriers. research programmes that shed clarity on the local Returnees coming back from Pakistan and Iran tend to reality and create more inclusive and transparent place a high value on education. In many of the LASs consultation processes with Afghan civil society to inform there are no schools above the primary level or the the development of comprehensive policy directives and schools are not placed in safe areas. Lack of employment strategies. opportunities and poverty hinder families from sending Sustained donor funding must be coupled with a shift their children to school, either because they cannot afford in policy and programming direction. Significant gains the cost or transportation or the loss of extra labour. have been made in increasing quantity in both the health and education sectors. the BphS was an effective mechanism for rol ing out the rapid expansion of primary healthcare services across the country immediately after 2001. The significant investments in TTCs and school construction have increased access to education for thousands of Afghan students. In education more focus needs to be put on learning outcomes and standardisation, teacher retention and building teaching healthcare workers, improving monitoring and evaluation capacity. in health the focus needs to be on the technical and standardising quality assurance procedures for capacity of service providers, increasing the skil s medicine. Outcomes and impact should be informing of future policy direction rather than inputs and outputs.
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Sustainability is dependent upon the development of CONCLUSION Many positive impacts have been made in the areas of coherent, implementable policy frameworks that address local realities and needs. the 2010 BphS revisions have health and education over the past ten years. the positive yet to be implemented, almost 15 months later. The EPHS developments that have been made have raised the from 2005, where it is being implemented, has shown a expectations of the people for access to quality education number of shortcomings in its design, range of clinical and health services. however, progress has been uneven and diagnostic services, staff structure and drug lists. and heavily linked to increases in quantity not quality. to the revision of BphS in 2010 was not followed date, international investment has been too focused on by adjustments in the EPHS. The MoPH lacks increasing visible infrastructure and building the legitimacy comprehensive policy frameworks and programming for of a government. It is imperative that future assistance is given free of political agendas and focused on the real needs major health sub-sectors such as disability and mental of the people. There has been a drop in the motivation of the health.87 instead, they have just been incorporated as components of the BPHS. The planned activities have yet population to support initiatives in their areas. in addition, both physical and psychological insecurity has had a serious to be implemented due to a lack of funding and unrealistic impact the ability of local people to access services and the human resource management planning. The lack of coherence and communication within and between the quality of those services. Communities are becoming more ministries involved in education and other stakeholders pessimistic and feel less able to influence the processes hinders the development of an organised and ef ective that are taking place. future aid programmes should focus educational system. on substantive achievements, such as increasing the Policy and programming that just build upon previous quality of services, training and standards of professionals policies or benchmarks without being informed by the in health and education. Adequate services are not being provided, particularly in the rural areas, and as a result there reality on the ground create a skewed picture of the is growing dissatisfaction and disil usionment among the situation in Afghanistan and act as bar iers to progress and Afghan public. sustainability. Such policies and programmes are indicative It is important that the international community continues to of those that are created without adequate consultation and invest heavily in both sectors but this investment now needs input from civil society and communities. Afghanistan is one of the largest recipients of international to shift focus. it needs to be redirected to strengthening the quality of services and further improving access. Significant aid in the world and has been dependent upon foreign aid effort needs to be placed in developing practical human to sustain itself and provide services to the population resource management plans and strategies, coupled for decades for over 60 years.88 Sustainability cannot be achieved if the health and education sectors continue with improved training and educational opportunities to be completely dependant on international aid and and incentives for people from rural and remote areas, if that aid fails to develop the quality of those sectors. marginalised groups and women. The NGO community The ability of the government to absorb, disburse and needs to increase their efforts to strengthen monitoring mechanisms in insecure and difficult to access areas in order monitor aid needs to be strengthened. Cost effectiveness analysis of contracting in services and the further to enhance the quality of services provided. The complexity development of internal revenue mechanisms will shed of the security situation needs to be addressed and flexible policies adopted that speak to the variety of issues that clarity on the sustainability of service delivery and allow the government to begin moving away from complete aid emerge due to insecurity. A balancing act needs to occur dependency. to level the playing field between the urban and rural divide and between the insecure areas with heavy investments and the ‘secure’ areas that have been marginalised. The improvements that have been made in women’s health and education, though laudable, are fragile and reversible and therefore require continuous commitment to become long-term achievements. Ef ective and rigorous monitoring systems and research and baseline data col ection initiatives recognises the reality in rural and remote areas and within need to be implemented to facilitate programming vulnerable communities, such as migrants and persons with that disabilities and mental health concerns.
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Financial disbursement mechanisms at the MoPH need to A WAY FORWARD: be strengthened to ensure timely disbursement of funds to NGOs providing services. This wil limit interruptions to RECOMMENDATIONS service delivery due to funding gaps. moph needs to increase its capacity and expertise to Health –Specific institute strong quality control mechanisms over al imports of pharmaceuticals and medical supplies. Recommendations MoPH policy and programming needs to speak to Education – Specific the reality on the ground rather than previous policies on Recommendations paper. the BphS needs to provide adequate levels of The development of a national curriculum and its funding to service providers that gives them the flexibility standardised implementation across the country needs to to respond to the geographical barriers that hinder access be given priority. Curriculum and teaching materials need to remote and mountainous areas. to be language appropriate and consistent. monitoring Stronger coordination between the moph, the moe of teachers’ understanding of the curriculum, the extent and MoHE needs to take place. The three of its use across the country and the resultant learning ministries outcomes for students must be incorporated into the need to work together to identify key areas of need and government’s strategic planning process. develop recruitment plans to fil those gaps. For example, The MoE needs to prioritise the development and preferential schemes should be developed for students coming from rural areas in medical training institutes to build the pool of trained healthcare staf from outlying areas. To ensure the “brain drain” from these areas is at Donors should adopt uniform financial and technical least staged, mandatory service in rural areas could be selection procedures so that al areas receive similar implemented as part of the certification process. levels of healthcare assistance. Contractors need to be selected based on the technical superiority of proposals accreditation of teachers that are currently teaching rather than the lowest cost. An accepted province- but do not met the minimum educational requirements. specific minimum threshold should be established Training programmes in rural areas need to be prioritised to exclude proposals that are financial y unreasonable. to address the gap between urban and rural quality of education. This is particularly important for female teachers that are limited by movement restrictions. this wil also be an incentive for teachers to relocate to rural areas if they know they wil stil be able to access professional development opportunities.
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The TTC model itself needs to be revised to ensure that it produces teachers who wil enter the educational system and achieve its objectives. A mandatory stage of two years and guaranteed placement should be implemented to ensure teacher retention after graduation. this would ensure that the number of graduates more accurately reflects the number of teachers entering the public school system. Lessons learned and best practices from other post-conflict countries might be useful in this respect. National standards for examination and graduation need to be implemented. These standards need to be enforced by the development of specific grading guidelines, stressed during training at the ttCs and rol ed out through specific training programmes among teachers and administrators that already are in service. Significant ef orts at strengthening the horizontal and vertical coordination and consistency in the ministries involved in education need to be undertaken. The flow of information from the provinces to Kabul must be regularised. Stronger oversight and anti-corruption mechanisms need to be put in place to address inconsistency, patronage and corruption. An extensive assessment of the scope and needs of the disabled community in Afghanistan needs to be undertaken in a coordinated ef ort by the moe, ministry of higher education (mohe) and the ministry of labour, Social Af airs, martyrs and disabled (molSAmd). Accredited programmes for special needs education should be developed and implemented in the Teacher training Col eges (ttCs) and higher education institutes, along with an incentive scheme which recognises the need in the community and special skil s that educators who take the course would require. the provision of organised transportation to schools in areas where they are located more than 3km from the vil age needs to be incorporated into the government’s strategic plans. A targeted needs assessment should be conducted which determines the academic and professional upgrades most needed by faculty at higher education institutes. Alternative options to sending faculty abroad, such as distance learning, summer or executive programmes and linkages with professional development institutes in other countries, could facilitate the simultaneous development of faculty whilst al owing the students to benefit from their newly developed skil s in the short term. This would also ensure that the investment made was returned to the country.
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BIBLIOGRAPHY
Adam Smith International (ASI). (2010). Education Sector Karlsson, P., & Mansoury, A. (2008). Islamic and Modern Education in
Afghanistan -. Stockholm University: Institute of International Education. Report, lopez Cardoza, B., & etal. (2004). mental health, Social functioning, Afghanistan. kabul: ASi. and Disability in Post-War Afghanistan. Journal of the American Medical Afghanistan ministry of education (moe). (2010). national education Association , 292 (5), 575-584. Strategic plan for Afghanistan 2010 – 2014. kabul: moe. majidi, n. (2010). research Study on the Coping Strategies of returned Afghanistan ministry of education (moe). (2011). response to education refugees in urban Set ings. kabul: norweigan refugee Council. for Al global monitoring report. kabul: moe. Masoury, A. (2010). Do Children Learn in Afghan Schools? Kabul: Swedish Afghanistan Ministry of Education (MoE). (2009). Summary Report of the Commit ee of Afghanistan. education Situation. kabul: moe. michael, m. (2011). “to good to Be true” : the Case of Afghanistan. Afghanistan Ministry of Education. (2011). www.moe.gov.af. Retrieved Providing Health Care in Severely Disrupted Environments: Multi-Country 2011 Study . Afghanistan ministry of public health (moph). (2010). A Basic package of Ministry of Finance. (2011). Development Cooperation Report. Kabul: health Services for Afghanistan. kabul: moph. mof.
Afghanistan ministry of public health (moph). (2011). Strategic plan for minority rights group international. (2008). World directory of minorities the ministry of public health. kabul: moph. and indigenous peoples - Afghanistan : kuchis. minority groups
Afghanistan Ministry of Rehabilitation and Rural Development (MRRD); international. Central Statistics organisation (CSo). (2008). national risk and Reed, S., & Foley, C. (2009). Land and Property: Chal enges and Vulnerability Assessment. Kabul: European Commission. opportunities for returnees and internal y displaced people in
Asian Development Bank (ADB), South Asia Department. (2003). A New Afghanistan. kabul: norweigan refugee Council (nrC). Start for the Afghan education Sector. manil a: AdB. Saito, m. (2008). the Afghanistan research and evaluation unit (Areu)
Asian Development Bank, S. A. (2003). A New Start for the Afghan paper “From Disappointment to Hope: Transforming Experiences of Young education Sector. manil a: AdB. Afghans Returning “Home” from Pakistan and Iran”. Kabul: Afghanistan
Belay, T. A. (2010). Building on Early Gains in Afghanistan’s Health, reseacrh and evaluation unit. nutrition, and population Sector. Washington: World Bank (WB). uneSCo. (2000). education for Al 2000 report . new york: uneSCo. Christensen, A. (1995). Aiding Afghanistan, The Background and United Nations Development Programme (UNDP). (2005). Mil ennium
Prospects for Reconstruction in a Fragmented Society. Copenhagen: Development Goals: Progress at a Glance. New York: UNDP. nordic institute of Asian Studies. United Nations Development Programme (UNDP). (2007). National Joint
Educational Quality Improvement Programme 2 (EQUIP2). (2008). Youth Programme, Annual Report. Kabul: UNDP.
Opportunity to Learn: A high impact strategy for improving educational United Nations Economic, Scientific and Cultural Organisation (UNESCO). outcomes in developing countries. Kabul: USAID. (2011). EFA Global Monitoring Report: The hidden crisis: Armed conflict
EQUIP2. (2008). Opportunity to Learn: A high impact strategy for improving and education. place de fontenoy: uneSCo. educational outcomes in developing countries. EQUIP2 Working Paper. United Nations General Assembly. (2011). Report on Children in Armed Geneva Conventions. (1977). Protocol Additional to the Geneva Conflict. New York: United Nations.
Conventions of 12 August 1949, and relating to the Protection of Victims United Nations Security Council. (2011). Resolutino 1998 (2011). New of International Armed Conflicts (Protocol I), 8 June 1977. york: united nations. Glad, M. (2009). Knowledge Under Fire. Kabul: CARE International. Wardak, H. a. (2009). Defining the GAPS: THE CASE OF AFGHANISTAN:
Government of Afghanistan (GoIRA ). (2011). National Priority Programme From Education Reforms to Sustainable Development. Kabul: Ministry of - education for Al . kabul: goirA . education.
Government of Afghanistan (GoIRA ). (2011). National Priority Programme WHO. (2006). Health Systems Profile- Afghanistan Regional Health - expanding higher education opportunities for Al . kabul: goirA . Systems Observatory. World Health Organisation. Winthrop, r., & kirk, J. (2006). home-BASed SChooling: ACCeSS Government of Afghanistan (GoIRA ). (2011). Socio-Economic and to QuAlity eduCAtion for AfghAn girlS. Journal of education Governance Standing Commit ees, Synthesis Paper. Kabul: GoIRA . for International Development , 2 (2). handicap international (hi). (2005). understanding the Chal enge Ahead. Winthrop, R., & Kirk, J. (2006). Meeting EFA: Afghanistan Home-Based national disability Survey in Afghanistan. kabul: hi. Schoolsintroductionyears. kabul: uSAid. Human Rights Reserach and Advocacy Consortium. (2007). Parents World Bank (WB). (2011). Afghanistan - reproductive health at a glance. and Children Speak Out: Is the Government Provided Basic Education World Bank. Fulfil ing Afghan Children’s Rights? Kabul: Human Rights Reserach and World Health Organisation (WHO). (2006). Health Systems Profile- Advocacy Consortium. Afghanistan Regional Health Systems Observatory. Kabul: World Health Human Rights Watch (HRW). (2008). Universal Periodic Review - organisation. Afghanistan. New York: Human Rights Watch. International Crisis Group. (2011). Aid and Conflict in Afghanistan.
Jackson, A. (2011). high Stakes: girls education in Afghanistan. kabul: oxfAm gB.
Page 40 Health and Education in Afghanistan: 10 Years After – Quantity Not Quality ACBAR Agency Coordinating Body for Afghan Relief
ENDNOTES
1. Various reports from the Government and Ministry of Public Health by various stakeholders to outline the linkages between npps and (MoPH) of Afghanistan put the figure at over 80% from 2010. transition. Consensus was reached that npps are suppose to lay 2. Government of Afghanistan, National Priority Programme: Education the foundations for transformation and, as such, are the framework for Al , 2011. for socio-economic and governance transition. 3. See Table 4: External Assistance for Reconstruction and Development 21. World Bank, reproductive health, 2011, p. 5. only (2002-2010) 22. Afghanistan ministry of education (moe), response to education for 4. ABCAr is a coordination body, based in Afghanistan, of over Al global monitoring report. kabul. 2011, p. 2.
100 organisations, which aims to address the humanitarian and 23. United Nations Secretary Council 1998 (2011) was adopted by the development needs of Afghans. Security Council at its 6581st meeting, on 12 July 2011.
5. 100% of the focus groups and regional workshops conducted 24. United Nations, Children in Armed Conflict Report, Report of the
throughout the country as part of the research study said that positive Secretary general, 23 April 2011, p. 14: paragraph 57. changes had been made over the last ten years. 25. United Nations, Children in Armed Conflict Report, Report of
6. The lack of census data in Afghanistan makes it difficult to know the Secretary general, 23 April 2011, p. 52 Annex 1: parties in the exact percentage of the total population that are youth. undp, Afghanistan.
National Joint Youth Programme, Annual Report 2007, puts the figure 26. geneva Conventions, protocol Additional to the geneva Conventions
at 68% of the population being under 25. The Afghanistan Research of 12 August 1949, and relating to the Protection of Victims of
and Evaluation Unit (AREU) paper “From Disappointment to Hope: International Armed Conflicts (Protocol I), 8 June 1977. Transforming Experiences of Young Afghans Returning “Home” from 27. michael, m., “to good to Be true”: the Case of Afghanistan. Pakistan and Iran”, (2008) claims 71% of the population is under 29. Providing Health Care in Severely Disrupted Environments: Multi-
7. A “shura” is a consultative group of men or women, often composed Country Study, 2011, p.8. of tribal elders, that come together to listen, discuss and decide on 28. Afghanistan, ministry of public health (moph), Strategic plan for the
issues af ecting the community. They are an important cultural, social ministry of public health. kabul: moph, 2011, p. 18.
and sometimes political structure in Afghan society most commonly 29. MoPH, Strategic Plan, 2011, p.49
found at the local level. Shuras also exist at the regional, provincial, 30. Belay, t. A., Building on early gains, 2010, p.26. national and international level. 31. Afghanistan Central Statistics Office, National Risk and Vulnerability 8. The word “Kuchi” means ‘nomad’ in the Dari (Persian) language. Kuchis are Pashtun nomadic people, who mainly come from southern Assessment. Kabul. 2008, p. 97 – 100.
and eastern Afghanistan. Though traditional y nomadic, many now 32. Afghanistan ministry of public health (moph), A Basic package of live in permanent set lements across Afghanistan. Thousands of health Services for Afghanistan . kabul. 2010, p. 4.
Kuchis, however, stil fol ow their traditional livelihood of nomadic 33. Government of Afghanistan (GoIRA), Socio-Economic and
herding. Others have become farmers, set led in cities or immigrated. Governance Standing Commit ees, Synthesis Paper. Kabul: GoIRA.
Source: minority rights group international, 2008. World directory of 2011, p. 12. minorities and indigenous people. 34. moe, response to education for Al . 2011, p. 3-4.
9. For the purposes of the research study “youth” was defined as 35. Afghanistan moe, national education Strategic plan for Afghanistan anyone under 30. 2010 – 2014. kabul, 2010, p.118-120. 10. The gender balance of females to males across al youth and 36. Adam Smith International (ASI), Education Sector Anaylsis Report, disabled persons focus groups was approximately 20/80. In the LDM Afghanistan, kabul. 2010, p. 20.
focus group the ratio was significantly lower. This was mainly due to 37. ASI, Education Sector Anaylsis. 2010, p. 19. the fact that female LDMs often felt more comfortable sharing their 38. Ministry of Education Website, Statistics, www.moe.gov.af opinions in the female only focus groups. 39. Ministry of Education, Summary Report of the Education Situation.
11. “triangulation” is a research technique that facilitates the validation
of data by the application and combination of several research methodologies in the study of the same phenomenon. Kabul. 2009. p. 2. 12. World Bank, Afghanistan – reproductive health at a glance. 2011, 40. Government of Afghanistan. Expanding Opportunities For Higher p.5. Education, National Priority Programme. Kabul. 2011, p. 2.
13. Belay, T.A., Building on Early Gains in Afghanistan’s, Health Nutrition 41. World Bank, Building on early gains, 2010, p. 106-107. and population Sector. World Bank, 2010, p.28. 42. MoE, www.moe.gov.af 14. UNDP, AFGHANISTAN - Mil ennium Development Goals: Progress 43. Government of Afghanistan (GoIRA ), National Priority Programme : at a glance. 2005, p. 2. education for Al . kabul. 2011, p. 3. 15. Asian Development Bank, A New Start for the Afghan Education 44. Wardak, H. A., Defining The Gaps: The Case Of Afghanistan: From Sector. manil a, 2003. Education Reforms To Sustainable Development. 2009, p. 6-7. 16. The BPHS was implemented in 2003 and the EPHS was endorsed 45. goirA , education for Al . 2011, p. 11. two years later in 2005, p. 8. (uneSCo). efA global monitoring report: the hidden Crisis: 17. Afghanistan Ministry of Finance, Development Cooperation Report, Armed Conflict and Education, 2011, p.150. kabul. 2011, p. 15 – 27. 19. In 2000, when the Mil ennium Development Goals were set by most
18. United Nations Economic, Scientific and Cultural Organisation countries in the world, Afghanistan did not participate in the 2000 UN Summit. It signed the Mil ennium Declaration in 2004 and set 46. Winthrop, R., & Kirk, J., Home-Based Schooling: Access to Quality
Afghan specific targets to be achieved by 2020. An additional goal of education for Afghan girls. Journal of education for international ‘enhancing security’ was included. Development, 2 (2), 2006, p. 12. 20. in 2010, under the guidance of the Afghanistan national 47. World Health Organisation (WHO), Report of the Health System
Development Strategy (ANDS), Afghan Ministries grouped together review mission - Afghanistan Chal enges and the Way forward, in clusters to prioritize ANDS initiatives in the form of National Priority 2006, p. 7. Programmes (NPPs). In May 2011, a workshop was held in Kabul 48. GOIRA, Synthesis Paper. 2011, p. 19 – 20. 49. moph, Strategic plan, 2011- 2015, 2011, p. 62. 50. michael, m., “to good to Be true”: the Case of Afghanistan. 2011. p, 5. 51. interviews conducted with a variety of stakeholders in Afghanistan put the lowest cost per capita between 2.5 – 3.5. 52. goirA, Synthesis paper. 2011, p. 18.
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53. MoE, www.moe.gov.af 54. goirA, education for Al . 2011, p.11. 55. Masoury, A, Do Children Learn in Afghan Schools? Kabul: Swedish Commit ee of Afghanistan. 2010, p. 3, 10-15. 56. goirA , education for Al . 2011, p. 10. 57. Jackson, A., High Stakes Girls’ Education in Afghanistan. Kabul: oxfAm. 2011, p. 11. 58. Human Rights Research and Advocacy Consortium. Parents Speak Out: Is the Government provided Basic Education Fulfil ing Afghan Children’s Rights. September 2007, p. 11. 59. ASi, education Sector report, Afghanistan. 2010, p. 26 – 27. 60. MoE, Summary Report. 2009, p. 17. 61. ASi, education Sector report, Afghanistan. 2010, p. 27.
62. EQUIP2, Opportunity to Learn: A high impact strategy for improving
educational outcomes in developing countries. EQUIP2 Working paper, 2008, p. 3-5. 63. goirA , education for Al , 2011, p.16 -17.
64. goirA, expanding opportunities for higher education. 2011, p.2 and 5. 65. goirA, expanding opportunities for higher education, 2011, p. 7. 66. Jackson, A., High Stakes Girls’ Education in Afghanistan. Kabul: oxfAm. 2011, p. 12. 67. ASI, Education Sector Report, Afghanistan. 2010, p.94 - 96.
68. Human Rights Watch, Universal Periodic Review Submission Afghanistan. 2008, p.2- 3. 69. uneSCo. efA global monitoring report. 2011, p. 306 70. A “Dia” is an older woman in the vil age that assist with childbirth. 71. Jackson, A., High Stakes Girls’ Education in Afghanistan. Kabul: oxfAm. 2011, p. 12.
72. Jackson, A., High Stakes Girls’ Education in Afghanistan. Kabul: oxfAm. 2011, p. 13. 73. World Bank, Building on Gains, 2010, p. 59. 74. MoE , www.moe.gov.af 75. GoIRA , Education For Al . 2009, p. 9. 76. Glad, M, Knowledge Under Fire. Kabul: CARE International, 2009, p. 3. 77. MoE, www.moe.gov.af 78. handicap international, understanding the Chal enge Ahead. national disability Survey in Afghanistan. kabul, 2005, p. 26. 79. lopez Cardoza, B. et al, mental health, Social functioning, and Disability in Post-War Afghanistan. 2004, 292(5):575-584.
80. According to the moph BphS 2010 revision, the disability and
Mental Health elements of the 2005 edition of the BPHS did not have any funds or staf al ocated to either programme.
81. handicap international, understanding the Chal enge Ahead. 2005, p. 74.
82. handicap international, understanding the Chal enge Ahead. 2005, p. 33-39.
83. land and property: Chal enges and opportunities for returnees and internal y displaced people in Afghanistan, Shelia reed and Conor Foley, NRC, (2009) 84. research Study on the Coping Strategies of returned refugees in Urban Set ings, Nassim Majidi, NRC, 2010 85. International Crisis Group, Aid and Conflict in Afghanistan. 2011, p.i. 86. MoF, Development Cooperation Report. 2011, p. 23. 87. michael, “to good to Be true” : the Case of Afghanistan. 2011, p. 7 and 24.
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